Review Cephalad–caudad versus transverse blunt expansion of the low transverse uterine incision during cesarean delivery Serena Xodo a , Gabriele Saccone b , Antonella Cromi c , Pinar Ozcan d , Emanuela Spagnolo e , Vincenzo Berghella f, * a Department of Gynaecology and Obstetrics, School of Medicine, University of Udine, Udine, Italy b Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy c Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy d Department of Gynaecology and Obstetrics, Bezmialem Vakif University Hospital, Istanbul, Turkey e Department of Perinatal Medicine, Policlinico Abano Terme, Padova, Italy f Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Comment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 European Journal of Obstetrics & Gynecology and Reproductive Biology 202 (2016) 75–80 A R T I C L E I N F O Article history: Received 11 March 2016 Received in revised form 9 April 2016 Accepted 23 April 2016 Keywords: Cesarean section Review Postpartum hemorrhage Metaanalysis Surgery A B S T R A C T It is imperative to have evidence-based guidelines for cesarean delivery. The aim of this meta-analysis was to evaluate the effectiveness of a cephalad–caudad compared to transverse blunt expansion of the uterine incision to reduce blood loss in women who underwent low-segment transverse cesarean delivery. We therefore performed a systematic search in electronic databases from their inception until March 2016. We included all randomized trials comparing cephalad–caudad versus transverse (control group) blunt expansion of the uterine incision in women who underwent a low transverse cesarean delivery. The primary outcome was postpartum blood loss, defined as the mean amount of blood loss (mL). Two trials (921 women) were analyzed. After the transverse uterine incision in the lower uterine segment with the scalpel, the uterine incision was then bluntly expanded by the designated method. Blunt expansion of the primary incision was derived by placing the index fingers of the operating surgeon into the incision and pulling the fingers apart laterally (transverse group) or cephalad (cephalad–caudad group). Women who were randomized in the cephalad–caudad group had lower: mean of postpartum blood loss, hemoglobin drop and hematocrit drop 24 h after cesarean, unintended extension, uterine vessels injury, blood loss >1500 mL and need for additional stitches. There was no statistically significant difference in the incidence of blood loss >1000 mL, in the operating time and in post-operative pain. In conclusion, expansion of the uterine incision with fingers in a cephalad–caudad direction is associated with better maternal outcomes and, therefore, should be preferred to transverse expansion during a cesarean delivery. ß 2016 Elsevier Ireland Ltd. All rights reserved. Abbreviations: CD, cesarean delivery; RCTs, randomized clinical trials; Hgb, hemoglobin; Hct, hematocrit; RR, relative risk; MD, mean difference; CI, confidence interval. * Corresponding author at: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, 833 Chestnut Street, First Floor, Philadelphia, PA 19107, USA. Tel.: +1 215 955 7996; fax: +1 215 955 5041. E-mail address: vincenzo.berghella@jefferson.edu (V. Berghella). Contents lists available at ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb http://dx.doi.org/10.1016/j.ejogrb.2016.04.035 0301-2115/ß 2016 Elsevier Ireland Ltd. All rights reserved.