ElNoury-Webster bundle: a preemptive surgical approach with a modified lower B-Lynch compression suture to manage morbidly low or adherent placenta.

OBJECTIVE: To report the technique and outcomes of a surgical care bundle, which preemptively and prophylactically reduces intrapartum bleeding during cesarean sections for these conditions and hence reducing the risk for a cesarean hysterectomy. METHODS: In this report, we present the surgical and clinical outcomes of a case series of 16 patients presenting with a morbidly low or adherent placenta on whom this technique was piloted. RESULTS: Seven of the sixteen patients (44%) required a blood transfusion ranging from 1 to 5 units of packed RBCs. None of the neonates required neonatal unit admissions. One woman had a subsequent pregnancy, with normal placentation and an uncomplicated delivery by cesarean section. None of the patients in our series had a hysterectomy, needed to return to theater after the initial surgery or had secondary postpartum hemorrhage. CONCLUSIONS: The ElNoury-Webster Bundle is a stepwise surgical technique for the conservative management of morbidly low or adherent placenta particularly in low and middle-income healthcare settings.

Transverse versus longitudinal blunt extension of the uterine incision during cesarean section in women with a uterine scar of previous cesarean delivery: A randomized controlled trial.

OBJECTIVE: To compare two different blunt extension techniques of the lower segment transverse uterine incision at cesarean delivery in women with a uterine scar of previous cesarean delivery. METHODS: Study design: Prospective single-blinded parallel multi-center randomized controlled trial involving 392 cases equally divided into two groups. Group one had their incision extended transversely, while group two had their incision extended longitudinally. OUTCOME MEASURES: The primary outcome was the unintended extension of the uterine incision, while the secondary outcomes included the need for additional stitches to achieve hemostasis, the drop in hemoglobin level, uterine vessels injury, and the need for blood transfusion. RESULTS: No significant difference between the transverse and longitudinal extension of the uterine incision during cesarean section as regards unintended uterine extension (P = 0.860), uterine vessel injury (P = 0.501), and cases requiring blood transfusion (P = 0.814). Significantly lower drop in hemoglobin level (P ≤ 0.001) and significantly less need for additional stitches (P ≤ 0.001) in cases with the longitudinal extension of uterine incision. CONCLUSION: In women with a uterine scar of previous cesarean delivery, the blunt longitudinal extension of the uterine incision in the lower segment cesarean section didn't differ from the blunt transverse extension as regards unintended uterine extension but is associated with less hemoglobin drop and less need for additional stitches as compared to transverse extension of the incision. Further studies are needed to assess the long-term complications of both techniques.