Adhesion Barrier Not Helpful for Cesarean Delivery

Laurie Barclay, MD

April 08, 2014

Use of a commercially available carboxymethylcellulose adhesion barrier at primary cesarean delivery did not reduce time to delivery, total operative time, or complications during repeat cesareans, according to findings of a retrospective cohort study published in the May issue of Obstetrics & Gynecology.

"Adhesions that occur as a result of a prior cesarean delivery have been implicated as one cause of delayed delivery of the neonate during repeat cesarean deliveries," write Rodney K. Edwards, MD, associate professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama Birmingham School of Medicine, and colleagues. "Seprafilm (sodium hyaluronate and carboxymethylcellulose absorbable adhesion barrier) is a commercially available product that is indicated for use in patients undergoing abdominal or pelvic laparotomy as an adjunct that is intended to reduce the incidence, extent, and severity of adhesion formation between the abdominal wall and the intraabdominal viscera.... However, data regarding use of this product for adhesion prevention at the time of caesarean delivery are limited to a single study of 52 patients."

Therefore, Dr. Edwards and colleagues evaluated the relationship between placement of such an adhesion barrier during primary cesarean delivery and clinical outcomes of repeat cesarean deliveries. The cohort for this study consisted of women who had primary cesarean delivery on or after January 1, 2008, and their first repeat cesarean delivery by June 30, 2011, in 1 of 4 hospitals in the same system.

Inclusion criteria were both infants being live singletons of gestational age 34 to 42 weeks, both deliveries through transverse abdominal incisions, and the first hysterotomy being low transverse. Women were excluded if they had an intervening delivery, laparotomy, or uterine incision; puerperal infection or bowel or bladder injury at primary cesarean delivery; or use of another adhesion barrier at primary cesarean delivery.

The main study endpoint was time from skin incision to neonate delivery during the repeat caesarean delivery, as a substitute marker for adhesion grading. Other outcomes were total operative time and rates of specific surgical complications.

Of 517 women included in the retrospective cohort, 248 received the adhesion barrier during primary cesarean delivery and 269 did not. With the exception of delivery hospital, demographic characteristics were similar between groups.

Adhesion Barrier Did Not Improve Outcomes

Time to delivery at repeat cesarean delivery did not differ between the groups, at 6.1 ± 3.0 minutes with previous use of the adhesion barrier and 5.8 ± 2.5 minutes without (P = .25). The groups also did not differ in total operative times (31.2 ± 10.6 vs 31.8 ± 11.6 minutes; P = .56) or in surgical complications.

"Placing a commercially available carboxymethylcellulose adhesion barrier at primary caesarean delivery is not associated with decreased time to delivery, total operative time, or complications during repeat cesarean deliveries," the study authors write.

Limitations of this study include retrospective design, use of a surrogate marker for adhesion grading, and inability to control for differences in surgical technique.

"In the absence of any data supporting improved outcomes with repeat cesarean deliveries, we think that the carboxymethylcellulose adhesion barrier should not be used during cesarean deliveries," the authors conclude. "The product is expensive; an estimate from a study evaluating the cost-effectiveness of this product for use during radical hysterectomy was $493 (U.S. dollars in 2006), and this amount is less than a recent estimate from our hospital purchasing officer. At that price, using the product during every cesarean delivery would cost approximately two-thirds of a billion dollars annually in the United States alone."

"Based on this study’s findings, carboxymethylcellulose barriers provide no direct patient benefit but do increase health care costs," writes Erika F. Werner, MD, from the Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island in Providence, in an accompanying editorial. "Accordingly, their routine use should be abandoned."

Departmental funds and a grant from Banner Good Samaritan Medical Center to Phoenix Perinatal Associates supported this study. The study authors and Dr. Werner have disclosed no relevant financial relationships.

Obstet Gynecol. 2014;123:919, 923-928.

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