Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial Everett F. Magann a, * , Suneet P. Chauhan b , Laura Bufkin a , Karen Field a , William E. Roberts a , James N. Martin Jr a Objective To determine whether the method used to expand the uterine incision for caesarean delivery affects the incidence of intra-operative haemorrhage. Design A prospective randomised study of women undergoing a low segment transverse caesarean delivery. Participants were assigned to have their uterine incision either sharply or bluntly expanded. Participants Between June 1998 and June 2000, 470 women drew assignments to the sharp expansion group and 475 to the blunt group. Results The maternal demographics of age, race, nulliparity, and body mass index as well as pre-operative haematocrit were similar between groups. Compared with the blunt group, the estimated blood loss (886 versus 843mL, P ¼ 0.001), change in the mean haematocrit (6.1% versus 5.5%, P ¼ 0.003), incidence of postpartum haemorrhage (13% versus 9%; relative risk ¼ 1.23, 95% CI 1.03, 1.46) and need for a transfusion (2% versus 0.4%; relative risk ¼ 1.65, 95% CI 1.25, 2.21) were significantly greater in the sharp group. Conclusion In caesarean delivery, sharply expanding the uterine incision significantly increases intra-operative blood loss and the need for subsequent transfusion. INTRODUCTION The most recent figures of maternal mortality in the United States are 7.5 maternal deaths per 100,000 live births 1 . Gherman et al. 2 found that obstetric haemorrhage, as well as pre-eclampsia and thromboembolic disease, accounts for the majority of these deaths. Obstetric haem- orrhage can occur in association with operative abdominal delivery 3 . In a recent investigation at our institution, we discovered that 8% of our caesarean deliveries are accom- panied by blood loss in excess of 1500mL and/or a drop in the haematocrit of 10% 4 . Several techniques have been proposed to reduce blood loss at operative abdominal delivery, including placental management (spontaneous compared with manual extraction) and in situ uterine incision repair compared with exteriorisation 5–7 . Another technique is uterine expansion (blunt versus sharp) of the uterine incision in low segment transverse caesarean deliveries 8 . Rodriguez et al. 8 reported no differ- ence between the methods of uterine expansion with respect to post-operative decrease in maternal hae- moglobin: blunt (1.8g/dL (0.1)) compared with sharp (2.2g/dL (0.2)). Although in Rodriguez’s study the blood loss was greater in the sharp group (147 patients) compared with the blunt group (139 patients), the difference was not significant. In light of the relatively small size of the investigation, our group wondered if a larger study group might exhibit the same findings. The purpose of this investigation was to determine which method of expanding the uterine incision at the time of operative delivery is associated with an increased risk of postpartum haemorrhage (decrease in haematocrit of 10% or more) or need for a packed red blood cell transfusion. METHODS All patients admitted to the University of Mississippi Medical Centre that were destined to deliver abdominally by primary or repeat low segment transverse uterine incision were invited to participate in this investigation. Exclusion criteria included women who declined to par- ticipate, women undergoing emergency surgery with insuf- ficient time to properly counsel the patient, and women in whom either a low segment vertical uterine or a classical upper segment were utilised. The Institutional Review Board of the University of Mississippi Medical Centre, Jackson, Mississippi, approved this investigation. Following study enrolment and completion of the informed consent, the women were randomised to either BJOG: an International Journal of Obstetrics and Gynaecology April 2002, Vol. 109, pp. 448–452 D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology PII:S1470-0328(02)01296-X www.bjog-elsevier.com a Department of Obstetrics and Gynaecology, University of Mississippi Medical Centre, Jackson, USA b The Spartanburg Regional Healthcare System, Spartanburg, Mississippi, USA * Correspondence: Professor E. F. Magann, Department of Obstetrics and Gynaecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216-4505, USA.