Evidence-based Cesarean Delivery: Intraoperative management following placental delivery until skin closure (Part 9): Evidence based care during cesarean delivery.

This expert review provides recommendations for the cesarean technique after placental delivery to skin closure. Following placental delivery during cesarean, sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable with some possible benefits with decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, one versus two-layer closure. Double layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness and full thickness bites (including endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and prior to closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion-prevention barriers, peritoneal closure, and rectus muscle re-approximation. Based on non-cesarean evidence, fascial closure bites should be at least 5 × 5 mm with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia either supra- or sub-fascial. Prior to closure, subcutaneous irrigation may be performed with saline, and routine use of subcutaneous drains is not recommended. Though closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥ 2cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the CD skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision the following may be considered: a DACC-impregnated dressing if available, otherwise a standard gauze dressing is appropriate. Prophylactic negative pressure would therapy can be considered in patients with obesity. Vaginal seeding at CD is not recommended.