Every year, tens of millions of babies are born via cesarean section (C-section), making it one of the world’s most common surgical procedures. In the United States alone, the CDC reported that roughly 32 percent of 2018’s 3.7 million births were via C-section (which comes out to about 1.2 million surgeries). C-sections are a vital tool, both in emergency and elective scenarios. As such, more expecting parents are delving into the specifics of C-sections to become fully informed and establish birth preferences to reflect their decisions. This is where particular aspects of a cesarean section, such as uterine exteriorization, come into play.
Most expectant parents are roughly familiar with the broad strokes of a C-section: the pregnant mom is taken to the operating room, a cut is made to the abdomen, another cut is made to the uterus, and the baby is taken out. Once the baby is born, the placenta needs to be removed from the uterus before the repairs begin.
The next step involves repairing the cut to the uterus. This is where your surgeon may consider uterine exteriorization. Essentially, this technique consists of removing the uterus from the body, allowing the surgeon to directly (and quickly) suture the uterine cut before returning the organ to the body. Once returned, the surgeon then sutures the abdominal incision as well.
The alternative to uterine exteriorization is called in situ repair, which involves keeping the uterus within the abdomen for the duration of the repair. There has been much debate within the OB/GYN community over which procedure should be the “standard of care” for repairing the uterus after delivery.
Initially, there was concern regarding blood loss and infection rates. However, most studies find comparable results with both uterine exteriorization and in situ repair. If there’s increased blood loss, it likely stems from the way the placenta is removed (manual removal, which increases blood loss, compared to spontaneous placenta removal).
Patients whose surgeons used uterine exteriorization did have statistically significant increased rates of nausea, vomiting, and pain both during the procedure and post-operation. This is thought to be a consequence of the increased stretch on the uterine ligaments and parietal peritoneum. These symptoms tend to be relatively short-term.
Benefits of uterine exteriorization include easier and faster repairs of the uterine incision, likely with more accuracy, as surgeons can see what they are doing more directly.
Currently, there are no studies specifically investigating longer-term outcomes (including additional pregnancies or VBACs) of patients with uterine exteriorization versus in situ repair. While there is still debate within the medical literature, a recently published commentary in Obstetrics & Gynecology looked at hundreds of previous trials and meta-analyses, issuing a general recommendation of uterine exteriorization. However, it is noted that if a patient has certain conditions, such as extensive intra-abdominal adhesive disease, she would need in situ repair instead.
Overwhelmingly, studies defer to the surgeon’s preference and expertise in deciding whether to use uterine exteriorization or in situ repair for a C-section.
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