Mechanical Dilatation of the Cervix at Elective Caesarean Section to Reduce Post-Operative Blood Loss
Condition: Post Operative Hemorrhage
MeSH terms: Hemorrhage; Blood Loss, Surgical; Postoperative Hemorrhage
Study type: Interventional

Summary: 
      obstetric hemorrhage remains one of the major causes of maternal death in both developed and
      developing countries. Because of its importance as a leading cause of maternal mortality and
      morbidity, and because of evidence of substandard care in the majority of fatal cases,
      obstetric hemorrhage must be considered as a priority topic for national guideline
      development.

      Some obstetricians believe that the cervix of women at non-labor cesarean section is
      undilated and might cause obstruction of blood or lochia drainage, leading to postpartum
      hemorrhage and endometritis from the collection of lochia or debris. Dilatation of the cervix
      helps with the drainage of blood during postpartum, reducing intrauterine infection or the
      risk of postpartum hemorrhage. To avoid this problem, some obstetricians routinely dilate the
      cervix from above during an elective/ non-labor cesarean section using finger, sponge forceps
      or other instruments
    

Detailed description: 
      Obstetric hemorrhage remains one of the major causes of maternal death in both developed and
      developing countries.

      Because of its importance as a leading cause of maternal mortality and morbidity, and because
      of evidence of substandard care in the majority of fatal cases, obstetric hemorrhage must be
      considered as a priority topic for national guideline development. Obstetric hemorrhage
      encompasses both antepartum and postpartum bleeding.

      The direct pregnancy-related maternal mortality rate in the United States is approximately
      7-10 women per 100,000 live births. National statistics suggest that approximately 8% of
      these deaths are caused by Post Partum Hemorrhage (PPH).

      In industrialized countries, PPH usually ranks in the top 3 causes of maternal mortality,
      along with embolism and hypertension. In the developing world, several countries have
      maternal mortality rates in excess of 1000 women per 100,000 live births, and World Health
      Organization statistics suggest that 25% of maternal deaths are due to PPH, accounting for
      more than 100,000 maternal deaths per year . The most recent Practice Bulletin from the
      American College of Obstetricians and Gynecologists places the estimate at 140,000 maternal
      deaths per year or 1 woman every 4 minutes. The rate of PPH increased from 1.5% in 1999 to
      4.1% in 2009, and the rate of atonic PPH rose from 1% in 1999 to 3.4% in 2009. In the
      triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy.
      The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths
      decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in
      2006-2008 (p = 0.02). The number of deaths from postpartum hemorrhage (PPH) has halved to
      ﬁve.

      In many countries cesarean section (CS) has become the mode of delivery in over a quarter of
      all births. It is the most commonly performed operation in obstetrics.

      Infectious morbidity is the most frequent complication of cesarean delivery. Of women who
      have caesareans, 5-24% have clinically significant fevers; and 6-21% are diagnosed with
      uterine infections (endomyometritis or endometritis), 1- 5% with more extensive pelvic
      infections including abscesses and 2-9% with a breakdown of the surgical incision, most often
      caused by wound infection. Strategies to minimize postoperative infectious and other
      morbidities have included modifications of surgical technique, changing of gloves, methods of
      placental delivery and altering the uterine position during repair of the uterine incision.

      However, none of these studies have evaluated the dilatation of the cervix during elective
      CS. The practice of routine cervical dilatation at elective cesarean section is performed by
      some surgeons to facilitate discharge of lochia from a uterus that was not in labor in the
      immediate postoperative period.

      A mechanical dilatation of the cervix at cesarean section is deﬁned as an artiﬁcial
      dilatation of the cervix performed by ﬁnger, sponge forceps or other instruments at non-labor
      cesarean section.An important concern when dilating the cervix in a non-labor uterus is the
      theoretical risk of ascending infection to the uterus from the vagina, abdominal cavity and
      abdominal incision. In addition, cervical dilatation may be associated with the creation of a
      false passage or hemorrhage from cervical injury. However, an undilated cervix may prevent
      discharge of lochia following elective CS with retention of lochia, a potential culture
      medium for bacteria, which can cause puerperal genital tract infection. Some published data
      from developed countries have suggested that there is no difference in outcome between a
      practice of routine cervical dilatation or non- dilatation at elective cesarean section.

      Turnbull's Obstetrics mentions using an extra glove on the left hand to dilate the cervix.
      The information currently available about the advantages of cervical dilatation at cesarean
      section is inconclusive. Therefore, evidence to support the effectiveness or safety of
      cervical dilatation at cesarean section is needed

      .
    

Intervention name(s): mechanical dilatation of the cervix
Intervention type(s): Procedure
Intervention description(s): the surgeon will perform the cervical dilatation by inserting the double-gloved index ﬁnger into the cervical canal of the patients after the extraction of placenta and membranes. The outer glove will be removed after this procedure.
- If failed the surgeon will use artery forceps to dilate cervix
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Prospective randomized controlled trial
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Prevention