UTERINE EXTERIORIZATION VERSUS IN-SITU REPAIR OF THE UTERINE INCISION AT CAESAREAN DELIVERY

TABLE OF CONTENTS

TITLE PAGE ............................................................................................................................. i

DECLARATION PAGE..............................................................................................................ii

CERTIFICATION PAGE BY SUPERVISORS.........................................................................iii

CERTIFICATION PAGE.BY HOD.................................................................................................iv

TABLE OF ABREVIATIONS........................................................................................................v

TABLE OF CONTENTS................................................................................................................vi

ABSTRACT...................................................................................................................................vii

CHAPTER1: INTRODUCTION……………………………..……………………………………...…………1

1.1. Justification of the study……………………………………….………………..… 3

CHAPTER 2: LITERATURE REVIEW…………………………………………………..….....4

2.1. Background………………………………………………………………………....4

2.2. Techniques in caesarean section………………………………………………….. .4

   2.2.1. Uterine exteriorization versus in situ repair………………………….…………4

   2.2.2. Abdominal incisions…………………………………………….………..……..7

   2.2.3. Uterine incisions………………………………….…………..…………………8

CHAPTER 3:   AIMS AND OBJECTIVES …………………………………………………...10

3.1. General Objective………………………………………………………………….10

3.2. Specific Objectives…...............................................................................................10

3.3. Hypotheses………………………………………..……...………………………..10

    3.3.1. Null hypothesis……………………………………………………………..…10

    3.3.2. Alternate hypothesis……………………………………………….………….10

CHAPTER 4: MATERIALS AND METHODS……………………….……….………………11

4.1  Study location………...……………….………………….………………………...11

4.2  Study design…………………………………………………..…………………….11

4.3  Study population……………….……………………………….….………………11

4.4  Inclusion criteria…………………………………………...………….…………….11

4.5  Exclusion criteria……………………………………………..……….……………12

4.6  Sample size determination………………………..……….…….……..…………..12

4.7  Study Period………………………………………..………………..…….……….13

 4.8 Subjects and methods…………………………………………………..………….13

4.9 Randomization………………………………………………….…………………..13

4.10 Pre-operative assessment …………………………………..……………………..13

4.11 Procedure for Caesarean section………………………………………………….14

4.12 Follow up. ……………………………………………….……………….………...17

4.13 Statistical Analyses………………………………………………….……………..18

4.14. Ethical considerations………………………………………………….………….18

Results ………………………………………………………………………...………..19

Tables of Results………………………………………………………….…………….21

Discussion……………………………………………………………………..………..25

Conclusion/Recommendation………………………………………………..………..29

Strength of the Study…………………………………………………………..….……29

Limitations………………………………………………………………………..…….30

References:……………………………………………………………………..………31

Appendices………………………………………………………………..……………36

Informed consent.…….…………………………………………….….………………36

Proforma………………….…………………………………………..….……………..37

Activity plan (Gantt chart) ………..………………………………………….………..38

ABSTRACT

Introduction:

The opinion appears divided on uterine exteriorization for uterine repair at Caesarean delivery. The available evidence appears insufficient to aid policy pronouncement of routine uterine exteriorization for repair of the lower segment incision. Whether or not it should be adopted as a routine remains unanswered question.

Aim:

 To evaluate the effect of extra-abdominal versus intra-abdominal repair of the uterine incision at Caesarean delivery.

Methods:

The study was a prospective, randomized and single blinded study conducted from April 2016 to December 2016. One hundred and seventy women were randomly assigned to groups; group ‘A’ had their repairs after exteriorization while group ‘B’ had in situ repair.. Outcomes measures include intraoperative blood loss, postpartum anaemia, transfusion rate, mean operative time, peri-operative, wound infection rate, nausea and vomiting, The data were compared using Fisher's exact test, chi-square and Student’s t test using SPSS version 20.  Significant level of 0.05 and confidence level of 95% were used to determine the significance. 

Results: A total of 170 women were randomized and data were available for analysis in 169 women that completed the study (exteriorization group [N=85] and in situ repair group [N=84])

Except for the statistically higher incidence of Nausea/vomiting among the women that had exteriorization when compared with their counterpart whose uteri were repaired in-situ (10.6% vs 2.4%;  p-value=0.031); there were similarities in all other tested variables. There were no statistically significant differences between the two groups in terms of the mean preoperative haematocrit (34.8% vs 35.7%), P=0.830; the mean postoperative haematocrit level (30.8±4.7 vs 30.8±4.9), p-value = 0.958;  the mean estimated blood loss  (575mls vs 577mls), p-value = 0.942 ; transfusion rate was (15.3%) in the exteriorization group  as against  (17.9%)  in the in situ group  (p-value=0.518 ); the post partum anaemia (35.3% vs 26.2% ), p= 0.200; operation time (57.5 vs 53.2 minutes), and the surgical site infection rate (1.2%  vs 1.2%).

Conclusion: Exteriorization and in- situ repair of uterine incisions have similarity in associated intraoperative blood loss, postoperative anaemia, duration of operation time and surgical site infections but,  the former is associated with significant higher perception of Nausea/vomiting. The choice of either method may therefore be at the surgeon’s discretion and familiarity provided the complaints of nausea/vomiting can be monitored and addressed accordingly. The findings could not categorically affirm the superiority of one over the other and perhaps, a large multi centre trials may be necessary to address the dilemma of which is to be considered superior.