Download PDF
Am J Perinatol 2019; 36(03): 277-284
DOI: 10.1055/s-0038-1667370
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Standardized Approach to Cesarean Surgical Technique and Its Effect on Operative Time and Surgical Morbidity

M. Pallister
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
,
J. Ballas
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
,
J. Kohn
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
,
C. S. Eppes
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
,
M. Belfort
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
,
C. Davidson
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
› Author Affiliations Funding None.
Further Information

Publication History

30 October 2017

26 June 2018

Publication Date:
06 August 2018 (online)

    Permissions and Reprints

Abstract

Objective To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity.

Materials and Methods Two-year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision-to-delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries.

Results When comparing pre- versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre- and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p < 0.01). Secondary outcomes were similar for both groups.

Conclusion A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity.

Keywords

standardized surgical technique - primary cesarean delivery - total operative time - incision-to-delivery time
 

  • References

  • 1 Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013; 209 (04) 294-306
    CrossrefPubMedGoogle Scholar
  • 2 Centers for Disease Control and Prevention. National Center for Health Statistics: Vital Statistics. Available at: http://www.cdc.gov/nchs/vitalstats.htm . Accessed May 2016
    PubMed
  • 3 Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Rep 2010; 29 (29) 1-20
    PubMedGoogle Scholar
  • 4 Boyle A, Reddy UM. Epidemiology of cesarean delivery: the scope of the problem. Semin Perinatol 2012; 36 (05) 308-314
    CrossrefPubMedGoogle Scholar
  • 5 Dahlke JD, Mendez-Figueroa H, Shim HG. , et al. Preferences in cesarean delivery surgical technique: a survey of maternal-fetal medicine fellows. J Matern Fetal Neonatal Med 2015; 28 (01) 77-81
    CrossrefPubMedGoogle Scholar
  • 6 Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol 2005; 193 (05) 1607-1617
    CrossrefPubMedGoogle Scholar
  • 7 Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database Syst Rev 2013; 5 (05) CD004453
    PubMedGoogle Scholar
  • 8 Karanth KL, Sathish N. Review of advantages of Joel-Cohen surgical abdominal incision in caesarean section: a basic science perspective. Med J Malaysia 2010; 65 (03) 204-208
    PubMedGoogle Scholar
  • 9 Menderes G, Athar Ali N, Aagaard K, Sangi-Haghpeykar H. Chlorhexidine-alcohol compared with povidone-iodine for surgical-site antisepsis in cesarean deliveries. Obstet Gynecol 2012; 120 (05) 1037-1044
    CrossrefPubMedGoogle Scholar
  • 10 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. ; Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20 (04) 250-278
    PubMedGoogle Scholar
  • 11 Holmgren G, Sjöholm L, Stark M. The Misgav Ladach method for cesarean section: method description. Acta Obstet Gynecol Scand 1999; 78 (07) 615-621
    CrossrefPubMedGoogle Scholar
  • 12 Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009; 201 (05) 431-444
    CrossrefPubMedGoogle Scholar
  • 13 Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the rectus sheath necessary during Pfannenstiel incision for lower segment Caesarean section? A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2006; 128 (1-2): 262-266
    CrossrefPubMedGoogle Scholar
  • 14 Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesarean necessary? A randomized trial. Obstet Gynecol 2001; 98 (06) 1089-1092
    PubMedGoogle Scholar
  • 15 Tuuli MG, Odibo AO, Fogertey P, Roehl K, Stamilio D, Macones GA. Utility of the bladder flap at cesarean delivery: a randomized controlled trial. Obstet Gynecol 2012; 119 (04) 815-821
    CrossrefPubMedGoogle Scholar
  • 16 Bujold E, Bujold C, Hamilton EF, Harel F, Gauthier RJ. The impact of a single-layer or double-layer closure on uterine rupture. Am J Obstet Gynecol 2002; 186 (06) 1326-1330
    CrossrefPubMedGoogle Scholar
  • 17 Bujold E, Goyet M, Marcoux S. , et al. The role of uterine closure in the risk of uterine rupture. Obstet Gynecol 2010; 116 (01) 43-50
    CrossrefPubMedGoogle Scholar
  • 18 Roberge S, Chaillet N, Boutin A. , et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet 2011; 115 (01) 5-10
    CrossrefPubMedGoogle Scholar
  • 19 Yazicioglu F, Gökdogan A, Kelekci S, Aygün M, Savan K. Incomplete healing of the uterine incision after caesarean section: Is it preventable?. Eur J Obstet Gynecol Reprod Biol 2006; 124 (01) 32-36
    CrossrefPubMedGoogle Scholar
  • 20 Kapustian V, Anteby EY, Gdalevich M, Shenhav S, Lavie O, Gemer O. Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study. Am J Obstet Gynecol 2012; 206 (01) 56.e1-56.e4
    CrossrefPubMedGoogle Scholar
  • 21 Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes. Cochrane Database Syst Rev 2014; 8 (08) CD000163
    PubMedGoogle Scholar
  • 22 Mackeen AD, Berghella V, Larsen ML. Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev 2012; 11: CD003577
    PubMedGoogle Scholar
  • 23 Rodriguez AI, Porter KB, O'Brien WF. Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section. Am J Obstet Gynecol 1994; 171 (04) 1022-1025
    CrossrefPubMedGoogle Scholar
  • 24 Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol 2008; 199 (03) 292.e1-292.e6
    CrossrefPubMedGoogle Scholar
  • 25 Figueroa D, Jauk VC, Szychowski JM. , et al. Surgical staples compared with subcuticular suture for skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol 2013; 121 (01) 33-38
    CrossrefPubMedGoogle Scholar
  • 26 Mackeen AD, Schuster M, Berghella V. Suture versus staples for skin closure after cesarean: a metaanalysis. Am J Obstet Gynecol 2015; 212 (05) 621.e1-621.e10
    CrossrefPubMedGoogle Scholar
  • 27 Anderson DJ, Kaye KS, Classen D. , et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 (Suppl 1): S51-S61
    CrossrefPubMedGoogle Scholar
  • 28 Rogers GM, Oetting TA, Lee AG. , et al. Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg 2009; 35 (11) 1956-1960
    CrossrefPubMedGoogle Scholar
  • 29 Lee AG, Greenlee E, Oetting TA. , et al. The Iowa ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency. Ophthalmology 2007; 114 (07) e21-e26
    CrossrefPubMedGoogle Scholar
  • 30 Aggarwal R, Grantcharov TP, Darzi A. Framework for systematic training and assessment of technical skills. J Am Coll Surg 2007; 204 (04) 697-705
    CrossrefPubMedGoogle Scholar
  • 31 Kloek CE, Borboli-Gerogiannis S, Chang K. , et al. A broadly applicable surgical teaching method: evaluation of a stepwise introduction to cataract surgery. J Surg Educ 2014; 71 (02) 169-175
    CrossrefPubMedGoogle Scholar
  • 32 Grantcharov TP, Reznick RK. Teaching procedural skills. BMJ 2008; 336 (7653): 1129-1131
    CrossrefPubMedGoogle Scholar