CC BY 4.0 · Surg J (N Y) 2017; 03(03): e128-e133
DOI: 10.1055/s-0037-1604074
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Rectus Muscle Reapproximation at Cesarean Delivery and Postoperative Pain: A Randomized Controlled Trial

Deirdre J. Lyell
1   Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Mariam Naqvi
1   Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Amy Wong
1   Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Renata Urban
1   Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Brendan Carvalho
2   Department of Anesthesia, Stanford University School of Medicine, Stanford, California
› Author Affiliations
Further Information

Publication History

22 November 2016

26 May 2017

Publication Date:
11 August 2017 (online)

Abstract

Objective Rectus muscle reapproximation at cesarean delivery (CD) is performed frequently by some obstetricians; however, the effect on postoperative pain is unclear. To this end, we investigated whether rectus muscle reapproximation increases postoperative pain.

Materials and Methods This is a prospective, double-blind, randomized controlled trial of women undergoing primary CD with singleton or twin pregnancy at >35 weeks' gestation. Women were randomized to rectus muscle reapproximation with three interrupted sutures or no reapproximation. Exclusion criteria were prior cesarean, prior laparotomy, vertical skin incision, active labor, chronic analgesia use, allergy to opioid or nonsteroidal anti-inflammatory drugs, and body mass index ≥ 40. Intra- and postoperative pain management was standardized within the study protocol. The primary outcome was a combined movement pain and opioid use score averaged over the 72-hour study period, called the Silverman integrated assessment. Movement pain scores were assessed at 24, 48, and 72 postoperative hours.

Results In total, 63 women were randomized, of whom 35 underwent rectus muscle reapproximation and 28 did not. Demographic and obstetric variables were similar between groups. Silverman integrated assessment scores during the 72-hour postoperative period were higher in the rectus muscle reapproximation group (15 ± 100% vs. –31 ± 78% difference from the mean; p = 0.04). Operative times were similar between groups (63 ± 15 vs. 65 ± 15 minutes; p = 0.61), and there were no surgical complications in either group. Maternal satisfaction with analgesia at 72 hours was high in both groups (85% [73–90] rectus muscle reapproximation vs. 90% [75–100]; p = 0.16).

Conclusion Rectus muscle reapproximation increased immediate postoperative pain without differences in operative time, surgical complications, or maternal satisfaction. Benefits of rectus muscle reapproximation should be weighed against increased postoperative pain, and analgesia should be planned accordingly.

 
  • References

  • 1 Centers for Disease Control and Prevention. National Center for Health Statistics. Available at www.cdc.gov/nchs/fastats/delivery.htm . Accessed December 9, 2015
  • 2 Demers S, Roberge S, Afiuni YA, Chaillet N, Girard I, Bujold E. Survey on uterine closure and other techniques for caesarean section among Quebec's obstetrician-gynaecologists. J Obstet Gynaecol Can 2013; 35 (04) 329-333
  • 3 Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988; 68 (07) 1082-1086
  • 4 Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18 (03) 321-328
  • 5 Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol 2005; 193 (05) 1607-1617
  • 6 Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013; 209 (04) 294-306
  • 7 Lyell DJ, Caughey AB, Hu E, Blumenfeld Y, El-Sayed YY, Daniels K. Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions. Am J Obstet Gynecol 2012; 206 (06) 515.e1-515.e5
  • 8 Gordon DB, Stevenson KK, Griffie J, Muchka S, Rapp C, Ford-Roberts K. Opioid equianalgesic calculations. J Palliat Med 1999; 2 (02) 209-218
  • 9 Silverman DG, O'Connor TZ, Brull SJ. Integrated assessment of pain scores and rescue morphine use during studies of analgesic efficacy. Anesth Analg 1993; 77 (01) 168-170
  • 10 Encarnacion B, Zlatnik MG. Cesarean delivery technique: evidence or tradition? A review of the evidence-based cesarean delivery. Obstet Gynecol Surv 2012; 67 (08) 483-494
  • 11 Dai F, Silverman DG, Chelly JE, Li J, Belfer I, Qin L. Integration of pain score and morphine consumption in analgesic clinical studies. J Pain 2013; 14 (08) 767-77.e8
  • 12 Hull DB, Varner MW. A randomized study of closure of the peritoneum at cesarean delivery. Obstet Gynecol 1991; 77 (06) 818-821
  • 13 Højberg KE, Aagaard J, Laursen H, Diab L, Secher NJ. Closure versus non-closure of peritoneum at cesarean section--evaluation of pain. A randomized study. Acta Obstet Gynecol Scand 1998; 77 (07) 741-745
  • 14 Rafique Z, Shibli KU, Russell IF, Lindow SW. A randomised controlled trial of the closure or non-closure of peritoneum at caesarean section: effect on post-operative pain. BJOG 2002; 109 (06) 694-698
  • 15 Shahin AY, Osman AM. Parietal peritoneal closure and persistent postcesarean pain. Int J Gynaecol Obstet 2009; 104 (02) 135-139
  • 16 Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol 2005; 106 (02) 275-280
  • 17 Mackeen AD, Schuster M, Berghella V. Suture versus staples for skin closure after cesarean: a metaanalysis. Am J Obstet Gynecol 2015; 212 (05) 621.e1-621.e10