A New Technique for Uterine Incision Closure at The Time of Cesarean Section: Does it Make a Difference

The investigators performed single site randomized clinical trial that was conducted at department of Obstetrics and Gynecology, Menoufia University Hospital, which is a large tertiary center in the Delta region in Egypt. The study population consisted of 120 eligible pregnant women with a singleton first-time cesarean delivery without preterm rupture of membranes, contractions or cervical dilatations that were recruited from the inward section one day before surgery from January 2017 to April 2019; only 114 cases remained for analysis. The study was approved by our hospital ethics committee and a written consent was obtained from each participant woman after full explanation of the study design. No important changes occurred to the trial design after it began, and the CONSORT guidelines was observed and completed.

Exclusion criteria were: pregnant women who refused to participate, women under age of 18 years, history of previous CS or any other uterine surgery ( Hystrotomy , myomectomy, perforation),placenta previa, abruptio placenta, fibroids located in the cervical or the cervico-corporal border, presence of maternal disease ( diabetes mellitus, anemia, connective tissue disorders, uterine malformations), reoperation following the CS, and presence of chorioamnionits. Secondary exclusion criteria were the need for more than three additional single sutures for hemostasis.

One author evaluated all obstetric patients who applied to the delivery room within the study period and selected eligible cases. After excluding patients who did not meet the inclusion criteria and patients who refused to participate, all remaining patients were equally randomized into either classical double layer uterine closure (group I), purse string double layer uterine closure (Turan technique, group II), or our technique of double layer step up- step down uterine closure (group III).

A computer-generated random numerical table (Randomization Generator Version 1.0) was used by our statistical department to prepare sealed opaque envelopes containing a group assignment. Three groups of envelopes-corresponding to the study groups were given to an anesthesia nurse. The nurse distributed envelopes to patients, alternating between groups during preanesthetic consultation. The patients were blinded the groups, and two authors performed the operations randomly. Another author who was blinded to the suturing technique performed all of the ultrasonographic examinations at 6 week follow up visit.

All cesarean deliveries were performed under spinal anesthesia. An abdominal opening was made through a slightly curved transverse incision that was placed 3-4 cm above the symphysis pubis (Pfannestiel incision). The subcutaneous tissue was left untouched apart from midline. The rectus sheath was separated along its fibers and the rectus muscles pulled apart. Stretching with index fingers opened the peritoneum and the uterus was opened by transverse lower segment incision (Kerr incision), then the hole was enlarged between the index finger of one hand and the thumb of the other hand.