Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : QC22 - QC26 Full Version

Evidence-based Analysis of Primary Caesarean Section Techniques Amongst Obstetricians: A Questionnaire-based Cross-sectional Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/60891.17335
Priya Sharma, Vartika Tripathi, Aditya Vikram, Swati Dubey, Uma Gupta

1. Associate Professor, Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India. 2. Assistant Professor, Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India. 3. Assistant Professor, Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India. 4. Assistant Professor, Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India. 5. Professor, Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Priya Sharma,
M-4/66, Vinay Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India.
E-mail: dr.sharma.priya@gmail.com

Abstract

Introduction: Caesarean Section (CS) despite being one of the most commonly performed surgeries in the world has a wide variation in its techniques. To improve the outcomes of CS through rectification of the surgical techniques, it is imperative to assess the current practices amongst the obstetricians and analyse the rationale behind their surgical preferences.

Aim: To assess the surgical techniques used for primary CS by obstetricians and review them with respect to the current evidence.

Materials and Methods: The present descriptive, questionnaire-based, cross-sectional study was carried out in the Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India, in the month of May 2020. A total of 400 Obstetricians possessing diploma or degree in the speciality performing CS and willing to participate in the study were included. A pretested questionnaire majorly focused on the various surgical techniques of primary CS, performed by the obstetricians, was distributed online. A total 203 respondents completed the questionnaire and their response was recorded. Analysis of Variance (ANOVA), Independent samples t-test and Chi-square test were used to analyse the data.

Results: Majority (n=140, 68.96%) of the respondents were between 25-40 years of age. In the study population, 8 (3.94%) were male respondents and 195 (96.06%) were female respondents with experience of <5 years. The most consistently used technique was the creation of bladder flap (187, 92.11%), while the least common was use of vertical incision (6, 2.9%) for opening the abdomen. There was a huge variation in the method of opening of the abdomen with 117 (57.6%) of obstetricians using blunt versus 86 (42.36%) using sharp dissection. The blunt extension of uterine incision was significantly associated with the increasing years of practice, whereas the preference to use Pfannensteil incision was significantly associated with the younger obstetricians.

Conclusion: There was heterogeneity and variation in the CS techniques being practiced by the obstetricians. These varied practices were the result of surgeon preferences, their training and difficulty in unlearning the long used surgical techniques. These are bound to continue until strong evidence-based guidelines for the techniques of CS are formulated.

Keywords

Bladder flap, Pfannensteil incision, Surgical techniques, Survey

The Caesarean Sections (CS) are one of the most commonly performed operations worldwide. The WHO recommends an acceptable caesarean section rate of 10-15% for any population (1). While, as per the latest data from National Family Health Survey 2019-2020 (NFHS-5), the caesarean rate at population level in India is 21.5% (2). Although CS is one of the most commonly practiced operation, a consensus on the most appropriate technique has not yet been reached, mostly because well-designed studies and solid evidences have been sparse (3). This is mainly due to the fast evolving of CS techniques with rapidly changing evidence. Therefore, the techniques used for the procedure vary widely amongst surgeons. Besides lack of evidence the variations in the surgical technique can also be attributed to personal preferences and differences in training.

Standardised approach to caesarean delivery can possibly have three advantages. Firstly, it will improve safe, efficient, effective healthcare delivery to women. Secondly, it can bring more consistency in the training of obstetrics and gynaecology residents. Thirdly, it can help in strengthening of future trials on caeasarean delivery techniques (4). To improve the outcomes of CS through rectification of the surgical techniques, it is imperative to assess the current practices amongst the obstetricians and analyse the rationale behind their surgical preferences.

The aim of the present study was to review the surgical techniques used for CS by obstetricians and to evaluate and compare with the existing evidence. The surgical techniques chosen by different surgeons in relation to their level of seniority were also assessed. This study expected to give an insight into the ongoing practices and their level of adherence to the contemporary evidence.

Material and Methods

This descriptive, questionnaire based, cross-sectional study was conducted in the Department of Obstetrics and Gynaecology, Mayo Institute of Medical Sciences, Barabanki, Lucknow, Uttar Pradesh, India, in the month of May, 2020. The ethical clearance was taken from Institutional Ethics Committee (Number- MIMS/EX/2020/101).

Inclusion criteria: Obstetricians holding diploma or degree in the speciality who performed CS and willing to participate in the study were included in the study.

Exclusion criteria: Those who did not give consent to participate were excluded from the study.

Participants were contacted through local Obstetrics and Gynaecology societies (Lucknow, Etawah, Agra). A pretested questionnaire, which was prepared on Google forms, was distributed to them online. One week time was given to fill up the questionnaire.

Sample size calculation: The following formula was used to calculate the required sample size:

n=(z)2 p (1-p)/d2
n=sample size
z=level of confidence according to the standard normal distribution (for a level of confidence of 95%, z=1.96)
p=estimated proportion of the population that presents the characteristic
d=tolerated margin of error

Based on a previous study, where the prevalence of double-layer hysterotomy closure, the most frequently used techniques for uterine closure among obstetricians, was 73% with a confidence interval of 95% and 7% margin of error, the minimum sample size required was 154 (5).

Questionnaire

The questionnaire was designed in English language and divided into two sections. The first part of the questionnaire includes four questions regarding demographic variables of the respondents like their age, gender, whether working in private or public health facility and years of postresidency practice. The second part dealt with the CS techniques which the participants follow in practice. The participants were asked to answer the questions with respect to an uncomplicated CS of a primi gravida. It had 14 questions which analysed the various steps involved in the CS operation including the rationale behind their surgical preference. Pretest of the questionnaires in English language was carried out on 10 obstetricians. All information obtained from this study was kept confidential.

Statistical Analysis

Data analysis was done using Analysis of Variance (ANOVA), Independent samples t-test and Chi-square test. The data was analysed using Statistical Package for Social Sciences (SPSS) software version 21.0. A p-value less than 0.05 was considered as statistically significant.

Results

A total of 400 Obstetricians were contacted through local obstetrics and gynaecology societies and requested to fill the survey questionnaire online. A total of 203/400 respondents (50.75% response rate) completed the questionnaire and were enrolled in the study. Age of respondents ranged from 26-71 years. Majority (n=76, 37.43%) of respondents were aged <30 years. Out of total, eight (3.94%) were male respondents, and 195 (96.06%) were females. Majority 112 (55.17%) of respondents had a Postgraduation (PG) experience of <5. Number of respondents from private sector were 85 (41.88%) and public sector were 118 (58.12%), which was almost comparable (Table/Fig 1).

Majority (n=130, 64.03%) of the respondents preferred to give preoperative antibiotic one hour prior to surgery, 70 (34.48%) on the operation table and 3 (1.47%) after clamping of the cord. Thirty seven (18.23%) respondents did not practice parts preparation prior to surgery, 94 (46.31%) preferred trimming while 72 (35.46%) shaving as a method of parts preparation. More than half of the obstetricians 120 (59.11%) preferred patient’s vaginal preparation with povidone iodine and 83 (40.88%) did not prefer.

(Table/Fig 2) depicts the frequency of practiced surgical techniques of CS among respondents. The most consistently used technique in CS amongst obstetricians in North India is the creation of bladder flap (n=187, 92.11%), while the least commonly practiced technique is use of vertical incision (n=6, 2.9%) for opening of the abdomen in an uncomplicated CS of a primi gravida. There was a huge variation in the method of opening of the abdomen with 57.6% of obstetricians using blunt versus 42.36% using sharp dissection. The preference to extend the uterine incision bluntly was significantly associated with the increasing years of practice, whereas the preference to use Pfannensteil incision was significantly associated with the younger obstetricians, who had relatively lesser years of practice (Table/Fig 3)a,b. The preferred surgical techniques along with the reasons for choosing those techniques are enumerated in (Table/Fig 4).

Discussion

The CS despite being one of the most commonly performed surgeries in the world has a wide variation in its techniques. There is heterogeneity and variation in the CS techniques being practised among the obstetricians. This study was conducted with the aim to assess the surgical techniques used for primary CS by Obstetricians and review them with respect to the current evidence. The present study demonstrated that the most consistently used technique in CS amongst obstetricians in North India is the creation of bladder flap (n=187, 92.11%), while the least commonly practiced technique is use of vertical incision (n=6, 2.9%) for opening of the abdomen in an uncomplicated CS of a primi gravida. There was a huge variation in the method of opening of the abdomen with 57.6% of obstetricians using blunt versus 42.36% using sharp dissection. The preference to extend the uterine incision bluntly was significantly associated with the increasing years of practice, whereas the preference to use Pfannensteil incision was significantly associated with the younger obstetricians, who had relatively lesser years of practice.

Almost all of the participants choose to give antibiotic prior to surgery, two-thirds preferred one hour prior and one-third on the operation table. The current guidelines support a single dose of a first-generation cephalosporin given 15-60 minutes prior to skin incision as Per NICE guidelines 2021 (6). In a systematic review done by Bollig C et al., preoperative administration of antibiotic was associated with a significant reduction in the rate of endometritis compared with intraoperative administration (7). Thus, this practice was at par with the guidelines.

Recent Cochrane review suggests that hair removal at surgical site does not lower Surgical Site Infections (SSI), however if necessary to remove hair, the existing evidence suggests that clippers/chemical depilation are associated with fewer SSIs than shaving (8). In present study, 94 (46.31%) preferred trimming while 72 (35.46%) opted shaving as a method of parts preparation and 37 (18.23%) respondents did not practice preoperative parts preparation. So, this practice doesnot seem to be in accord with recent evidence. The reason for same might be the difficulty in “unlearning” the long term practices.

Authors that more than half of the respondents preferred preoperative vaginal preparation with Iodine. According to National Institute for Health and Care Excellence (NICE) guidelines, use of aqueous iodine vaginal preparation before caesarean birth in women with ruptured membranes help to reduce the risk of endometritis. If aqueous iodine vaginal preparation is not available or is contraindicated, aqueous chlorhexidine vaginal preparation can be used (6). Haas DM et al., did a Cochrane based systematic review and concluded that vaginal preparation with povidone-iodine immediately before caesarean delivery probably reduces the risk of postcaesarean endometritis (9). Also, supported by Guidelines for intraoperative care in caesarean delivery: Enhanced Recovery after Surgery Society Recommendations (Part 2) (10). So, this practice seems to be in accordance with the recent guidelines.

Almost all the obstetricians use a transverse incision, 80% prefer Pfannensteil while 15% choose Joel Cohen, similar to the findings of Tully L et al., in a survey done in UK where Pfannensteil incision was preferred by over 80% of the obstetricians (11).

The National Institute of Heath and Care Excellence (NICE) guidelines recommend a transverse incision rather than vertical (preferably Joel Cohen) as it is associated with less postoperative pain, improved cosmetic effect, shorter operating times and reduced postoperative febrile morbidity (6). The number of respondents opening the abdominal wall layers by blunt dissection was similar to those who use sharp dissection. In Randomised Control Trials (RCTs) and Cochrane reviews, sharp dissection versus blunt dissection and expansion of tissue layers after the skin incision was compared, with primary outcomes including operative time, postoperative analgesia requirements, febrile morbidity, blood loss, and duration of hospital stay. Techniques that incorporated sharp dissection and blunt tissue expansion and entry were favoured and supported by the Cochrane Review (4). We found a significant association between the preference to use Pfannensteil incision and the number of years of practice with younger obstetricians opting for Pfannensteil incision. Young obstetricians opting for transverse incision may reflect the effect of training, with those who received training in recent years were trained for transverse incision.

More than 90% of the participants created a bladder flap during CS and the most common reason quoted for the same was reduction in the incidence of bladder injury. However, in a study done by Cetin BA et al., concluded that intraoperative results and operation time are not affected by creation of bladder flap, however short-term urinary complaints, such as postoperative urinary retention and dysuria are increased (12). This was also supported by Jan-Simon Lanowski and Constantin S (3). According to them, intraoperative or postoperative complications such as blood loss, postoperative micro haematuria, postoperative pain, hospital days, endometritis, or urinary tract infection are not increased if formation of bladder flap is omitted both in primary and repeat CS but this shortened incision to delivery time. Thus, as per the current evidence, the routine bladder flap development and closure of the visceral peritoneum of the bladder flap cannot be recommended, but trials have been underpowered to assess morbidity such as bladder injury and adhesion formation (3),(4). In the present study, there seems to be a huge gap in knowledge and practice related to bladder flap development and thus recognises the difficulty in “unlearning” long used surgical techniques.

In the present study, more than half the obstetricians choose to extend the uterine incision bluntly due to reduction in blood loss. The NICE guidelines also cite that when lower uterine segment is well formed, blunt rather than sharp extension of the uterine incision should be used as it decreases blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS (3),(4),(6). This practice of blunt extension of the uterine incision was associated significantly with the years of practice of the obstetricians with senior obstetricians more in favour of blunt dissection. So, this practice seems to be at par with the guidelines.

Two-third of the respondents choose to exteriorise the uterus for repair of uterine incision since they felt it provided better exposure. The current evidence by NICE guidelines promotes intraperitoneal repair of the uterus because exteriorisation is associated with more pain and does not improve operative outcomes such as haemorrhage and infection (6). However, a RCT concluded that there is higher operative blood loss while performing the intraperitoneal repair of uterine incision compared to uterine exteriorisation. Rest of the operative and postoperative complication rates was found to be similar in both the groups (13). Thus, due to the lack of sufficient evidence to definitely recommend for or against routine exteriorisation, the findings in the present study remain as per surgeon preference. In present study, double layer running suture was the most commonly used technique for uterine closure followed by 1st layer interlocking and 2nd layer running. Similar to the results found by Lyell DJ et al., and Tully L et al., in their United States of America (USA) and the United Kingdom (UK) survey based surveys respectively, where most obstetricians were found to used double layer hysterotomy closure (5),(11). Contrary to a survey done by Demers S et al., in Quebec where 1st layer interlocking and 2nd layer running followed by double layer running sutures were preferred (14). In CORONIS trial single versus double layer closure of the uterus showed no evidence of a difference in maternal death or a composite of pregnancy complications (15); whereas the NICE guidelines and Enhanced Recovery After Surgery (ERAS) quotes that the effectiveness and safety of single layer closure of the uterine incision is uncertain, and the uterine incision should be sutured with two layers without specifying the preferred suture technique (6),(10),(16). Three-fourth of the participants were not found to practice the inclusion of deciduas while closing the uterus as they believe that it results in better scar integrity. Amongst the 25% of obstetricians who did not include the deciduas while suturing felt that this practice resulted in better haemostasis. Bujold E, suggested suture technique aiming to a correct approximation of the cut margins (decidua-to-decidua, myometrium to myometrium) leads to improved scar healing evident by ultrasound findings done six months following caesarean (17).

A greater number of obstetricians preferred to close the visceral as well as parietal peritoneum as most of them believed that it reduces the resulting adhesions. Contrary to the findings of Lyell DJ et al., where only 12% of the surgeons closed the visceral peritoneum while surgeons were almost equally divided in terms of closure of parietal peritoneum (5). The NICE guidelines and ERAS also support that neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time and the need for postoperative analgesia, and improves maternal satisfaction (6),(10). So, this practice of closure of both the peritoneum without any demonstrable benefit.

Rectus muscle closure was done by more than half of the study participants participants. In the US survey done by Leyll DJ et al., practices were found to be varied with respect to closure of the rectus muscle where almost similar number of respondents opted for both (5). Lyell DJ et al., also found that there is paucity of literature on rectus muscle approximation and hence no definite recommendations can be made regarding the same (5). Although author conducted a randomised controlled trial in 2017 and found that Rectus muscle reapproximation increased immediate postoperative pain without differences in operative time, surgical complications, or maternal satisfaction (18). About 70% of surveyed obstetricians preferred to close the subcutaneous layer. However, both the NICE guidelines updated in 2021 and ERAS cite against the routine closure of the subcutaneous tissue space and advise it only if the woman has more than 2 cm subcutaneous fat (6),(10). So, this practice does not seem to be at par with the current guidelines.

Limitation(s)

Practicing obstetrician from only the northern region was included in the study. Also, the response rate was low. This limits generalisability of results.

Conclusion

The CS despite being one of the most commonly performed surgeries in the world has a wide variation in its techniques as evident by the indexed study. The existing guidelines are not uniform regarding multiple issues due to paucity of data which is probably the reason for the heterogeneity of the surgical techniques being practised among the obstetricians. The other reasons responsible for such variation are the different ways in which obstetricians were trained and surgeon’s preference. These varied practices are bound to continue until strong evidence based guidelines for the techniques of CS are formulated.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/60891.17335

Date of Submission: Oct 18, 2022
Date of Peer Review: Nov 08, 2022
Date of Acceptance: Nov 30, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 19, 2022
• Manual Googling: Nov 11, 2022
• iThenticate Software: Nov 25, 2022 (14%)

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