Dahlke Joshua D, Mendez-Figueroa Hector, Sperling Jeffrey D, Maggio Lindsay, Connealy Brendan D, Chauhan Suneet P
Division of Maternal-Fetal Medicine, Nebraska Methodist Women's Hospital and Perinatal Center, Omaha, Nebraska, United States.
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UT Health-University of Texas Medical School at Houston, Texas, United States.
Surg J (N Y). 2015 Dec 18;2(1):e1-e6. doi: 10.1055/s-0035-1570316. eCollection 2016 Mar.
Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad-caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD.
剖宫产术（CD）是美国和全球范围内最常见的大型手术之一。在精心设计的随机对照试验（RCT）中评估的、显示对母体有益的手术技术应纳入临床实践。本综述的目的是总结该手术的技术要点，并为非产科医生回顾其证据基础。在可行的情况下，应常规采用以下证据最充分的技术：（1）皮肤切开前单次静脉注射氨苄西林或第一代头孢菌素作为预防性抗生素；（2）在4至8小时内，将10至40IU缩宫素加入1L晶体液中静脉滴注以预防产后出血；（3）低位横切口皮肤切口；（4）钝性或锐性分离皮下组织和筋膜；（5）钝性、上下方向扩展子宫切口；（6）自然娩出胎盘；（7）缝合时使用钝头针；（8）如果皮下组织厚度≥2cm，采用皮下连续或间断缝合；（9）皮肤缝合。尽管旨在优化这一常见手术的母婴结局的随机对照试验数量令人鼓舞，但仍需进一步努力以尽量减少手术并发症。预防产后出血、粘连和静脉血栓栓塞的最佳方法仍是积极研究的领域，其结果可能显著改善孕产妇的发病率和死亡率。如果一种手术技术的证据明显优于另一种，临床医生在实施和教授剖宫产术时应乐于采用基于证据的技术。
