What are the steps in closure following a cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Answer

Answer

If the uterine incision is hemostatic, the uterine fundus is replaced into the abdominal cavity (unless a concurrent tubal ligation is to be performed). The incision is re-inspected for hemostasis, and the bladder flap is also inspected. The paracolic gutters are visualized, and any blood clots are removed with laparotomy sponges. Although many surgeons perform abdominal irrigation, this does not appear advantageous. [97]

Peritoneal closure is no longer recommended as it is associated with increased adhesion formation and may increase surgical time as well as length of hospital stay. [98]

Furthermore these surfaces reapproximate within 24-48 hours and can heal without scar formation. [99] Furthermore, the rectus muscles to do not need to be reapproximated.

The subfascial and muscle tissue is inspected for bleeding, and, if hemostatic, the fascia is closed. The fascia can be closed with a running nonlocking stitch, and synthetic braided or monofilament sutures are preferred over chromic sutures. Chromic sutures do not maintain their tensile strength as long or as predictably as synthetic material. If the patient is at risk for poor wound healing (eg, from long-term steroid use), a delayed absorbable or permanent suture can be used. Place stitches at approximately 1-cm intervals and more than 1 cm away from the incision line.

The subcutaneous tissue should be inspected for hemostasis and can be irrigated according to physician preference. The subcutaneous tissue usually does not have to be reapproximated, but patients with subcutaneous depth greater than 2 cm may benefit from subcutaneous tissue closure. [100] Placement of drains is no longer recommended and has been shown to increase the risk of infection. In one multicenter randomized trial, women with suture closure and drain had a 22% risk of wound morbidity compared to 17% in the women with sutire closure but no drain. [101] If needed, a closed vacuum suction system should be used in the appropriate patients.

In a randomized controlled trial comparing postoperative pain according to method of skin closure after a cesarean delivery, Rousseau et al found that postoperative pain was significantly less and operative time shorter in patients closed with staples than those closed with subcuticular sutures group. [102] They concluded that staples should be the skin closure of choice for elective term cesareans. A subsequent meta-analysis determined that although staple closure is faster to perform, it is associated with a higher risk of wound complications. [103]  The skin edges should be closed with a subcuticular stitch as staples have shown to be associated with increased wound infection and wound disruption. [104]

A study by Buresch et al compared the results of 263 women who had received a poliglecaprone 25 suture following a Pfannenstiel skin incision and 257 women who had a polyglactin 910 suture. The study reported a decrease in the rate of wound complications with poliglecaprone 25 (8.8% vs 14.4%, relative risk 0.61, 95% CI 0.37-0.99; P=.04). [105]

If the patient has consented to a levonorgestrel subdermal implant prior to her cesarean delivery, then the device should be inserted in the patient's non-dominant arm using standard procedure. [15]


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