What are the guidelines for the treatment and surgery of cesarean section (CS) niche?

Guidelines for the Management of Cesarean Section Niche: Treatment and Surgical Approaches

The management of cesarean section (CS) niche should follow a standardized surgical approach with blunt expansion of the transverse uterine hysterotomy and two-layer closure of the hysterotomy to reduce the risk of uterine rupture and niche formation. 1

Surgical Techniques for Cesarean Delivery to Prevent Niche Formation

Uterine Incision and Expansion

• Blunt expansion of a transverse uterine hysterotomy is recommended to reduce surgical blood loss during cesarean delivery (Evidence level: Moderate, Recommendation grade: Weak) 1
• Vertical hysterotomy (classical cesarean section) should be limited to specific indications such as preterm labor, dense adhesions, or placenta previa/accreta where access to the lower uterine segment is difficult (Evidence level: Low, Recommendation grade: Strong) 2
• Vertical incisions in the contractile corpus carry a higher risk of uterine rupture in subsequent pregnancies and are contraindicated for trial of labor after cesarean section (Evidence level: Moderate, Recommendation grade: Strong) 2

Uterine Closure Technique

• Closure of the hysterotomy in 2 layers is associated with a lower rate of uterine rupture and niche formation (Evidence level: Moderate, Recommendation grade: Weak) 1
• The peritoneum does not need to be closed as closure is not associated with improved outcomes and increases operative times (Evidence level: Moderate, Recommendation grade: Weak) 1

Subcutaneous Tissue and Skin Closure

• In women with ≥2 cm of subcutaneous tissue, reapproximation of that tissue layer should be performed to reduce wound complications (Evidence level: Moderate, Recommendation grade: Weak) 1
• The skin should be closed with subcuticular suture in most cases, as this technique shows reduced wound separation compared to staples removed 4 days postoperatively (Evidence level: Moderate, Recommendation grade: Weak) 1

Perioperative Management to Optimize Surgical Outcomes

Antimicrobial Prophylaxis and Skin Preparation

• Intravenous antibiotics should be administered routinely within 60 minutes before the cesarean delivery skin incision (Evidence level: High, Recommendation grade: Strong) 1
• In all women, a first-generation cephalosporin is recommended; in women in labor or with ruptured membranes, the addition of azithromycin confers additional reduction in postoperative infections (Evidence level: High, Recommendation grade: Strong) 1
• Chlorhexidine-alcohol is preferred to aqueous povidone-iodine solution for abdominal skin cleansing before cesarean delivery (Evidence level: High, Recommendation grade: Strong) 1
• Vaginal preparation with povidone-iodine solution should be considered for the reduction of post-cesarean infections (Evidence level: High, Recommendation grade: Strong) 1

Anesthetic Management

• Regional anesthesia is the preferred method of anesthesia for cesarean delivery as part of an enhanced recovery protocol (Evidence level: Low, Recommendation grade: Strong) 1

Prevention of Intraoperative Hypothermia

• Appropriate patient monitoring is needed to apply warming devices and avoid hypothermia (Evidence level: Low, Recommendation grade: Strong) 1
• Forced air warming, intravenous fluid warming, and increasing operating room temperature are all recommended to prevent hypothermia during cesarean delivery (Evidence level: Low, Recommendation grade: Strong) 1

Perioperative Fluid Management

• Perioperative and intraoperative euvolemia are important factors in patient perioperative care and appear to lead to improved maternal and neonatal outcomes after cesarean delivery (Evidence level: Low-moderate, Recommendation grade: Strong) 1

Postoperative Care to Reduce Complications

Early Mobilization and Nutrition

• Gum chewing appears to be effective and is low risk for preventing postoperative ileus. It may be redundant if a policy for early oral intake is being used but should be considered if delayed oral intake is planned (Evidence level: Low, Recommendation grade: Weak) 1

Discharge Planning

• Standardized written discharge instructions should be used to facilitate discharge counseling (Evidence level: Low, Recommendation grade: Weak) 1
• The Perceived Readiness for Discharge After Birth Scale is a validated tool that may help clinicians identify patients at increased risk of problems after discharge (Evidence level: Low, Recommendation grade: Weak) 1

Surgical Management of Existing CS Niche

Indications for Surgical Repair

• Surgical repair of CS niche should be considered in women with abnormal uterine bleeding, pelvic pain, or secondary infertility attributed to the niche (Evidence level: Low, Recommendation grade: Weak) 3
• Repair should also be considered in women planning future pregnancies with a niche depth of more than 50% of the myometrial thickness to reduce the risk of uterine rupture, abnormal placentation, ectopic pregnancy, and preterm birth (Evidence level: Low, Recommendation grade: Weak) 3

Surgical Approaches for Niche Repair

• Hysteroscopic resection of the niche is appropriate for women with abnormal bleeding who have completed childbearing (Evidence level: Low, Recommendation grade: Weak) 3
• Laparoscopic or vaginal repair should be considered for women with deep niches (>50% of myometrial thickness) or those desiring future fertility (Evidence level: Low, Recommendation grade: Weak) 3
• Complete excision of fibrotic tissue at the niche site followed by layered closure of the myometrium is recommended during surgical repair (Evidence level: Low, Recommendation grade: Weak) 3

Prevention Strategies for High-Risk Populations

Risk Factor Identification

• Women with multiple previous cesarean deliveries have an increased risk for wound and uterine hematoma (4-6%), placenta previa (1-2%), red cell transfusions (1-4%), hysterectomy (0.5-4%), and placenta accreta (0.25-3%) (Evidence level: Moderate, Recommendation grade: Strong) 1

Quality Improvement Approaches

• Implementation of enhanced recovery after surgery (ERAS) protocols for cesarean delivery has been shown to result in clinical benefits (reductions in length of stay, complications, and readmissions) and health system benefits (reduction in cost) (Evidence level: Moderate, Recommendation grade: Strong) 1
• Continuous assessment of outcomes and quality improvement approaches are needed to incorporate best practices in cesarean delivery care (Evidence level: Low, Recommendation grade: Strong) 1

Pitfalls and Caveats in CS Niche Management

• The global cesarean section rate continues to increase across high-income, middle-income, and low-income countries, with projections showing that by 2030,28.5% of women worldwide will give birth by CS 4
• Cesarean delivery is associated with increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose-response manner with multiple cesarean deliveries 3
• Babies born by CS have different hormonal, physical, bacterial, and medical exposures that can alter neonatal physiology, with short-term risks including altered immune development, increased likelihood of allergy, atopy, asthma, and reduced intestinal gut microbiome diversity 3
• Socioeconomic disparities exist in accessing CS services, with higher rates observed among women with higher education and from middle or rich households 5

Audit and Quality Assessment

• Elements to consider for the creation of a clinical audit tool for CS niche management include: (1) that the audited pathway has an important impact in terms of costs, resources, or risk, (2) that strong scientific evidence is available, and (3) that improvements can be evaluated easily and become a source of important clinical/organizational consequences 1
• The ERAS cesarean delivery guideline/pathway has created a focused pathway with 5 preoperative elements (8 recommendations), 4 intraoperative elements (9 recommendations), 9 postoperative elements (11 recommendations), and 1 neonatal element (6 recommendations) 1
• More prospective and quality assessment/improvement research, evaluation, audit, and collaboration are required for the enhancement of maternal health outcomes, quality, and safety related to CS niche management 1