Is uterine exteriorization (externalization of the uterus) recommended during cesarean section (C-section)?

From the Guidelines

Uterine exteriorization during cesarean delivery is not recommended due to inconsistent procedure-specific evidence. The decision to use uterine exteriorization or in situ repair should be based on individual patient factors and clinical circumstances. According to the study published in Anaesthesia in 2021 1, uterine exteriorization has inconsistent procedure-specific evidence, which raises concerns about its effectiveness and potential side effects.

Key Considerations

• The study found that several surgical techniques, including uterine exteriorization, have limited or inconsistent evidence to support their use 1.
• The absence of strong evidence for uterine exteriorization suggests that it may not be the best approach for all patients.
• Surgeons should consider individual patient factors, such as the presence of adhesions or difficult uterine angles, when deciding between uterine exteriorization and in situ repair.

Alternative Approaches

• In situ repair may be a viable alternative to uterine exteriorization, particularly in cases where maintaining stable hemodynamics is a priority.
• The use of other surgical techniques, such as the Joel-Cohen incision and avoidance of peritoneum closure, may be beneficial in reducing postoperative pain and improving outcomes 1.

Conclusion is not allowed, so the answer just ends here.

From the Research

Uterine Exteriorization During Cesarean Delivery

• The recommendation for uterine exteriorization during cesarean delivery is not universally agreed upon, with various studies presenting different outcomes 2, 3, 4, 5, 6.
• Some studies suggest that uterine exteriorization may be associated with fewer post-operative febrile days and a non-significant trend towards fewer infections 2.
• However, other studies have found that in situ repair may be more advantageous than exteriorization with respect to mean operative time, time to the first recognized bowel movement, surgical site infection rate, and length of hospital stay 3.
• A systematic review and meta-analysis found that uterine exteriorization was associated with a higher risk of intraoperative nausea and vomiting, but no significant change in perioperative hemoglobin decrease compared with in situ repair 4.
• Another study found that estimated blood loss was not statistically different between the two methods of uterine repair, but exteriorization reduced the decrease in hemoglobin 5.
• A systematic review, equivalence meta-analysis, and trial sequential analysis found that estimated blood loss and surgical duration were equivalent between methods, but in situ repair was associated with faster return of bowel function and a reduction in need for breakthrough postoperative analgesia 6.

Comparison of Uterine Exteriorization and In Situ Repair

• The studies compared various outcomes, including:
  • Intraoperative nausea and vomiting
  • Perioperative hemoglobin concentration decrease
  • Estimated blood loss
  • Surgical site infection rate
  • Length of hospital stay
  • Time to return of bowel function
  • Postoperative analgesic use
• The results of these comparisons are inconsistent, with some studies finding advantages to uterine exteriorization and others finding advantages to in situ repair 2, 3, 4, 5, 6.

Clinical Implications

• The decision to use uterine exteriorization or in situ repair during cesarean delivery should be based on individual patient factors and clinical judgment 2, 3, 4, 5, 6.
• Further research is needed to fully understand the benefits and drawbacks of each approach and to inform evidence-based practice 2, 3, 4, 5, 6.