European Journal of Cardiovascular Medicine

Cesarean section (CS) is one of the most frequently performed surgical procedures worldwide and plays a crucial role in reducing maternal and neonatal morbidity and mortality (1,2). Advances in anesthesia, surgical techniques, antibiotic prophylaxis, and perioperative care have significantly improved cesarean outcomes (3,4). However, optimizing intraoperative techniques to ensure minimal complications and enhanced recovery remains a key focus in obstetric surgery.

One of the ongoing debates in cesarean section techniques is whether the uterus should be exteriorized for repair or left in situ. Exteriorization of the uterus involves temporarily delivering it onto the anterior abdominal wall for better surgical access before repositioning it inside the abdominal cavity. This technique is associated with improved visibility, reduced intraoperative blood loss, and shorter operative time (1,5). However, it has also been reported to cause hemodynamic instability, increased postoperative pain, nausea, and delayed recovery due to peritoneal traction and increased intraoperative exposure (6,7).

Conversely, in situ repair keeps the uterus within the abdominal cavity, potentially reducing postoperative discomfort and minimizing hemodynamic fluctuations. However, it may lead to longer surgical duration and increased blood loss due to limited visibility and accessibility (2,3,4). Despite multiple studies comparing these techniques, findings remain inconclusive, necessitating further clinical investigation (1,5,6).

Given the increasing global rates of cesarean deliveries, it is essential to establish an evidence-based approach to optimizing intraoperative techniques. This study aims to compare maternal and neonatal outcomes between exteriorization and in situ repair techniques during CS. By analyzing operative time, blood loss, pain scores, infection rates, and neonatal APGAR scores, this study seeks to provide clinically relevant insights for obstetricians to improve cesarean delivery outcomes

Study Design and Setting

This was a prospective interventional study conducted at the Department of Obstetrics and Gynecology, Konaseema Institute of Medical Sciences, Amalapuram, over a study period from December 2019 to September 2021. The primary objective of the study was to compare the maternal and neonatal outcomes of two different surgical techniques during cesarean section: exteriorization of the uterus versus in situ repair.

Study Population

The study included 200 patients undergoing cesarean section, who were randomly assigned to two groups:

Exteriorization group (n = 100): The uterus was delivered out of the abdominal cavity for repair.

In situ repair group (n = 100): The uterus was repaired within the abdominal cavity without exteriorization.

Inclusion Criteria

• Patients undergoing primary or repeat cesarean section.
• Both elective and emergency cases.
• Singleton or multiple pregnancies.
• Both booked and unbooked cases.
• Patients with fetal distress, previous LSCS, cephalopelvic disproportion, or failed induction.

Exclusion Criteria

• Previous classical cesarean section.
• Midline vertical incision on the skin.
• Inverted T or J-shaped uterine incisions.
• Cesarean hysterectomy or ruptured uterus.
• Cesarean section under general anesthesia.

Study Procedure

All cesarean sections were performed using a Pfannenstiel incision under spinal/epidural anesthesia. The placenta was removed spontaneously or manually, and the uterus was closed in either a single or double layer. In the exteriorization group, the uterus was temporarily removed from the abdominal cavity for repair and repositioned afterward. Postoperative parameters such as pain, analgesic use, febrile morbidity, and duration of hospital stay were recorded. Neonatal outcomes, including APGAR scores, were also assessed.

Outcome Measures

Primary Outcomes:

Duration of surgery (in minutes).

Blood loss (measured via postoperative hemoglobin levels).

Postoperative pain scores (using a Visual Analog Scale).

Hospital stay duration (in days).

Secondary Outcomes:

Incidence of febrile morbidity, cystitis, and wound infection.

Need for blood transfusion.

Neonatal APGAR scores at 1 and 5 minutes.

Statistical Analysis

Data were analyzed using IBM SPSS 16.0 software. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages. The Chi-square test was used for categorical comparisons, and the Student’s t-test for continuous variables. A p-value < 0.05 was considered statistically significant.

A prospective interventional study was conducted among 200 patients undergoing cesarean section at the Department of Obstetrics and Gynecology, Konaseema Institute of Medical Sciences, Amalapuram. The study aimed to compare the surgical outcomes of exteriorization of the uterus versus in situ repair during cesarean section.

Patient Demographics

The study population consisted primarily of women aged 20–29 years, with no statistically significant difference in age distribution between the two groups (p = 0.117) (Table 1). The majority of participants were primigravida (59% in the exteriorization group vs. 54% in the in situ group; p = 0.476) and booked cases (96% vs. 97%; p = 0.701). Term pregnancies were predominant in both groups (p = 0.306).

Table 1: Patient Demographics

Indications for Cesarean Section

The most common indication for cesarean section was fetal distress, observed in 36% of the exteriorization group and 33% of the in situ group, with no significant difference (p = 0.119) (Table 2). Other common indications included cephalopelvic disproportion (CPD) (14% vs. 18%) and previous LSCS (18% vs. 21%), both of which were statistically insignificant.

Table 2: Comparision Indications for Cesarean Section

Figure No:1Comparision Indications for Cesarean Section

Surgical Outcomes

The mean surgical duration was significantly lower in the exteriorization group (59.09 ± 10.46 min) than in the in situ group (66.15 ± 11.72 min; p < 0.0001) (Table 3). The spontaneous expulsion of the placenta was slightly lower in the exteriorization group (79%) compared to the in situ group (86%), though the difference was not statistically significant (p = 0.193).

Table 3: Comparision of Surgical Outcomes

Figure No:2. Comparision of Surgical Outcomes

Postoperative hemoglobin levels were significantly higher in the exteriorization group (10.28 ± 1.28 g/dl) compared to the in situ group (9.76 ± 0.89 g/dl, p = 0.001), suggesting lower intraoperative blood loss. The need for blood transfusion was minimal and did not differ significantly between groups (1% vs. 2%, p = 0.561).

Postoperative Morbidity and Recovery

Postoperative pain was higher in the exteriorization group, as indicated by a significantly greater pain score on day 1 (6.69 ± 0.84 vs. 5.43 ± 0.74; p < 0.0001) (Table 4). However, by day 2, there was no significant difference between the groups (p = 0.257).

The number of analgesic doses required on day 1 was higher in the exteriorization group (4.35 ± 0.88) compared to the in situ group (3.78 ± 0.52; p < 0.0001). However, by day 2, analgesic use was comparable (p = 0.967).

Table 4: Comparision of Postoperative Morbidity and Recovery

Figure No:3. Comparision of Postoperative Morbidity and Recovery

There was no statistically significant difference in hospital stay duration, with an average of 6.82 ± 0.56 days in the exteriorization group and 6.96 ± 0.46 days in the in situ group (p = 0.056).

Comparision of Neonatal Outcomes

The APGAR scores at 1 minute were identical in both groups (7.06 ± 0.47 in the exteriorization group vs. 7.06 ± 0.37 in the in situ group, p = 1.000) (Table 5). However, at 5 minutes, the in situ group had a slightly higher APGAR score (8.93 ± 0.26 vs. 8.79 ± 0.43, p = 0.005).

Table 5: Neonatal Outcomes

Figure No:4. Comparision of Neonatal Outcomes

Cesarean section is a critical obstetric intervention, and optimizing surgical techniques significantly impacts maternal and neonatal outcomes. This study compared uterine exteriorization versus in situ repair during cesarean delivery, evaluating key intraoperative and postoperative factors such as surgical duration, blood loss, postoperative pain, infection rates, and neonatal outcomes.

Surgical Duration and Blood Loss

Our study found that the exteriorization group had a significantly shorter operative time (59.09 ± 10.46 min vs. 66.15 ± 11.72 min, p < 0.0001, Table 3). These findings are consistent with previous studies, such as those by Gode et al. (8) and Tan et al. (9), which reported reduced surgical time with exteriorized repairs due to better surgical visibility and ease of suturing.

Postoperative hemoglobin levels were significantly higher in the exteriorization group (10.28 ± 1.28 g/dl vs. 9.76 ± 0.89 g/dl, p = 0.001), suggesting lower intraoperative blood loss, a result that aligns with Xiao et al. (11), who found that placental extraction in an exteriorized uterus minimized blood loss. However, Ozbay (10) found no significant difference in blood loss between the two techniques, indicating that surgeon expertise and intraoperative management play a role in these outcomes.

Postoperative Pain and Recovery

Despite shorter surgery times, the exteriorization group experienced significantly higher pain scores on postoperative day 1 (6.69 ± 0.84 vs. 5.43 ± 0.74, p < 0.0001, Table 4). This can be attributed to traction on uterine ligaments and peritoneal irritation during exteriorization, as reported by Abdellah et al. (12). However, pain scores became comparable by day 2 (p = 0.257), suggesting that the increased discomfort is transient.

Furthermore, postoperative analgesic requirements on day 1 were significantly higher in the exteriorization group (4.35 ± 0.88 doses vs. 3.78 ± 0.52 doses, p < 0.0001), reinforcing findings by Coutinho et al. (13) that patients undergoing exteriorization require increased opioid or non-opioid analgesia in the immediate postoperative period. By day 2, analgesic use was similar between the groups (p = 0.967), further supporting the transient nature of postoperative pain with exteriorization.

Infection Rates and Hospital Stay

Febrile morbidity, wound infections, and cystitis were low and did not differ significantly between groups, aligning with studies by Hofmeyr et al. (3) and Gode et al. (8). While some earlier research, such as Coutinho et al. (13), suggested a higher risk of infections with exteriorization, our study's strict aseptic techniques and prophylactic antibiotic use likely contributed to minimizing infection rates in both groups.

The mean hospital stay was slightly shorter in the exteriorization group (6.82 ± 0.56 days vs. 6.96 ± 0.46 days, p = 0.056, Table 4), but this difference was not statistically significant. Similar results were reported by Wang et al. (14), reinforcing that both techniques result in comparable hospital stay durations when standard perioperative management protocols are followed.

Neonatal Outcomes

Neonatal well-being was not affected by the surgical technique, as evidenced by no significant difference in 1-minute APGAR scores (p = 1.000, Table 5). These findings are consistent with Tan et al. (9), who reported that neonatal outcomes were not influenced by the choice of uterine repair technique. However, the 5-minute APGAR score was slightly higher in the in situ group (8.93 ± 0.26 vs. 8.79 ± 0.43, p = 0.005), which could be attributed to less intraoperative maternal stress and better hemodynamic stability, as suggested by Abdellah et al. (12).

Clinical Implications

Exteriorization significantly reduces operative time and intraoperative blood loss, making it a viable choice for reducing surgical morbidity (8,9,11). Postoperative pain is higher in the first 24 hours with exteriorization, but this difference diminishes by the second postoperative day (12,13). Both techniques show comparable infection rates, hospital stay duration, and neonatal outcomes, allowing surgeon preference and patient factors to dictate the approach

Limitations

This study has several limitations. The sample size may not be large enough to detect subtle differences in rare complications or long-term outcomes. The study was conducted at a single center, limiting its generalizability to different populations and settings. Additionally, surgeon variability in performing the procedures could influence results, and the non-randomized design may introduce selection bias. Lastly, subjective pain assessment and self-reported analgesic use may be prone to reporting bias, affecting the accuracy of postoperative recovery data.

This study demonstrates that both exteriorization and in situ repair of the uterus during cesarean section are safe and effective techniques with distinct advantages. Exteriorization significantly reduces operative time and intraoperative blood loss but is associated with higher immediate postoperative pain and increased analgesic use on the first day. Conversely, in situ repair provides better postoperative comfort but does not show a significant advantage in surgical outcomes, infection rates, or hospital stay duration. Neonatal outcomes, including APGAR scores, were comparable between the two techniques. Given these findings, the choice of technique should be individualized based on patient condition and surgeon preference. Further large-scale studies and randomized trials are required to establish definitive clinical guidelines.

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