Effect of Rectus Muscle Re-approximation and Postoperative Pain in Women with Previous Cesarean Delivery: A Randomized Controlled Trial

Abstract

Background Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. 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. Objective In women with previous cesarean delivery, the aim of this prospective double blind randomized controlled trial is to assess the effect of rectus muscle approximation on postoperative pain. Patients and Methods This study was a prospective, doubleblind, randomized controlled trial. It included 340 women with previous cesarean delivery, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group I (study group) in which rectus muscle approximation were done (surgeons were instructed to place three vertical midline loose interrupted sutures to re-approximate the rectus muscles by using Vicryl 0 suture) while in Group II (control group) rectus muscle approximation not done. Intra- and postoperative pain management was standardized within the study protocol. Results Both groups were comparable in age, body mass index (BMI), parity, gestational age (GA), sub-rectus hematoma, surgical site infection and subsequent hospital stay. While study group had significantly longer operation duration, significantly higher pain score from first day of operation and up to 6 weeks postoperative and significantly higher NSAID dose and opioid requirements at first and second day postoperative. Conclusion Our results suggest that rectus muscle reapproximation increases operative time & postoperative pain and subsequently associated with higher short-term postoperative opioid use among women undergoing cesarean section (CS). Surgical complications do not appear to be impacted by rectus muscle reapproximation. So, the benefits described with rectus muscle reapproximation such as less adhesions, should be weighed against the potential for a modest increased postoperative pain and corresponding opioid use.