The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

The effect of peritoneal cavity saline irrigation

at cesarean delivery on maternal morbidity and
gastrointestinal system outcomes

Osman Temizkan, Osman Asıcıoglu, Kemal Güngördük, Berhan Asıcıoglu,

Pınar Yalcin & Isil Ayhan

To cite this article: Osman Temizkan, Osman Asıcıoglu, Kemal Güngördük, Berhan Asıcıoglu,
Pınar Yalcin & Isil Ayhan (2015): The effect of peritoneal cavity saline irrigation at cesarean
delivery on maternal morbidity and gastrointestinal system outcomes, The Journal of
Maternal-Fetal & Neonatal Medicine

To link to this article: http://dx.doi.org/10.3109/14767058.2015.1015415

Published online: 24 Feb 2015.

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ISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, Early Online: 1–5

! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1015415

ORIGINAL ARTICLE

The effect of peritoneal cavity saline irrigation at cesarean delivery on

maternal morbidity and gastrointestinal system outcomes
Osman Temizkan1, Osman Asıcıoglu1, Kemal Güngördük2, Berhan Asıcıoglu3, Pınar Yalcin1, and Isil Ayhan1
1
Department of Gynecology and Obstetrics, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey, 2Department of Gynecological
Oncology, Tepecik Training and Research Hospital, Izmır, Turkey and 3Department of Gynecology and Obstetrics, Kanuni Sultan Suleyman Training
and Research Hospital, Istanbul, Turkey
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Abstract Keywords
Objective: The objective of this study is to investigate the effect of peritoneal cavity saline Cesarean, emesis, irrigation, nausea
irrigation during cesarean section (CS) on gastrointestinal disturbance and postoperative
infectious morbidity (PIM). History
Methods: This prospective randomized clinic trial included 430 women who underwent elective
or primary CS. The participants were randomized to either an irrigation of the abdominal cavity Received 14 January 2015
or the control group. The primary outcome measured was the rate of antiemetic drugs required Accepted 2 February 2015
in the postoperative period following CS. Secondary outcome measures included the rate of Published online 24 February 2015
PIM.
Results: Participants in both groups had similar demographic and clinical characteristics.
The rate of antiemetic drugs required by patients was significantly higher in the irrigation
group when compared with the control group (15.8% versus 8.4%, p ¼ 0.018). The rate
of intraoperative nausea and emesis (p  0.001) and the rate of postoperative nausea and
emesis (p  0.001 and p ¼ 0.018, respectively) were significantly higher in the irrigation group
compared with the control group.
Conclusions: Irrigation with saline at the time of CS increases both intraoperative and
postoperative nausea and emesis without any beneficial effects on PIM. Routine use of saline
irrigation in the abdominal cavity does not seem to be reasonable.

Introduction cavity at CS [12–14]. All these studies reported that

Cesarean section (CS) is the most frequently performed
intraperitoneal surgical operation worldwide [1,2]. Although
data on the rate of CS in Turkey are limited, a previous study
reported a rate of 18.2% [3]. Postoperative infectious
morbidities (PIM), such as endometritis and wound infection,
are frequent complications associated with CS [4]. Post
cesarean infection rates of up to 25% result in increased
hospitalization and care costs [5]. The most widely imple-
mented strategy for reducing postcesarean delivery febrile
morbidity is the administration of antibiotic prophylaxis.
Several strategies have been evaluated to minimize post-
operative infection and other morbidities, including surgical
technique, skin preparation, placental delivery method, and
altering the uterine position during repair of the uterine
incision [6–11].
To date, no recommendations have been made regarding
intra-abdominal irrigation in CS. A few studies have
evaluated the role of saline irrigation in the peritoneal
Address for correspondence: Osman Asıcıoglu, MD, Department of
Gynecology and Obstetrics, Sisli Hamidiye Etfal Training and Research
Hospital, 34360, Istanbul, Turkey. Tel: +90 507 140 32 44. Fax: +90 212
224 07 72. E-mail: oasicioglu@gmail.com
peritoneal cavity irrigation did not affect postoperative
morbidities or result in negative effects on gastrointestinal
(GI) outcomes.
However, no studies have evaluated this procedure using
a sufficient sample size to detect differences in outcomes.
The aim of the present study was to investigate the effect
of peritoneal cavity saline irrigation during CS on GI
disturbance and PIM.
Methods
The prospective randomized clinic study was conducted
between November 2012 and August 2014 at the Sisli
Hamidiye Etfal Education and Research hospital in Istanbul.
Approval for the study was obtained from the hospital’s ethics
committee. Written informed consent was obtained from all
the participants prior to enrollment in the study. Moreover, the
study was registered with the federal government
(NCT01716091).
Participant eligibility criteria for inclusion in the study
were gestational age greater than 38 weeks and elective
cesarean delivery. Patients with emergency cesarean delivery,
chorioamnionitis, type I diabetes, placenta previa, placenta
accreta, maternal coagulopathy, or prior severe
 2 O. Temizkan et al.
gastrointestinal disease were excluded. Elective CS was
defined as CS performed before the presence of labor with
or without previous CS history. Primary CS was defined as
women with no previous CS history.
Following informed consent, all participants completed a
form providing information on age, parity, body mass index,
existing comorbidities, and use of tobacco or alcohol. After
this, the participants were randomized to either an irrigation
group or a control group. Assignment to one of the two
treatment groups was determined using a random number
table. The assigned treatments were written on cards and
sealed in secure opaque envelopes numbered in sequence. The
surgeons were not blinded to the procedure allocation. The
allocated envelope was opened by the surgeon just before
surgery, and the procedure allocation was recorded on each
woman’s chart.
Before CS, a Foley catheter was inserted, and the hair on
the abdomen was shaved. The skin was cleaned with povidone
iodine solution. All operations were performed under regional
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anesthesia and the anesthetist used 5 mL of 0.5% bupivacaine
(Marcaine Spinal Heavy, AstraZeneca, Istanbul, Turkey). All
operations were performed by the first and second authors
(obstetrics and gynecology surgeons: O. A. and O. T.).
Pfannenstiel incisions were used on all patients. The fascial
aponeurosis was freed from the underlying rectus abdominis
muscles in both cranial and caudal directions. After the
caudal-cut aponeurosis was elevated under tension, the rectus
muscles were separated on midline. The peritoneum was
opened in an identical manner using a vertical midline
incision. A bladder flap was not created routinely. The uterine
incision was initially created with a scalpel to incise the lower
uterine segment transversely for 1–2 cm in the midline. The
uterine incision was then expanded using blunt methods.
The placenta was delivered by controlled cord traction. The
anesthetist administered a 5 IU intravenous bolus of oxytocin
(Syntocinon, Novartis, Basel, Switzerland) over 5–10 s to
each woman when the umbilical cord was clamped. Then,
30 IU of oxytocin in 500 mL lactated Ringer solution was
administered at a rate of 125 mL/h, and this was continued for
4 h. A total of 1 -g cefazolin diluted in 20 mL normal saline
was administered over a 5-min period. Patients were not given
any additional drugs intraoperatively. The uterine incision was
sutured without exteriorization of the uterus. After hemostasis
was secured, the irrigation group underwent irrigation of the
abdominal cavity using 500 mL of warm normal saline after
closure of the uterine incision but before closure of the
abdominal wall. All blood clots, vernix, and other debris were
evacuated from the paracolic gutters, anterior and posterior
cul-de sacs, and under the bladder flap when employed. In
patients assigned to the control group without irrigation, all
clots, vernix, and other debris were left in place. The
abdominal wall was closed in layers without closure of the
peritoneum. Occasional cauterization of subcutaneous tissue
was performed to secure hemostasis. The skin was closed
using 3-0 Vicryl sutures. If patients had nausea or emesis
during the cesarean delivery, the observation was recorded
systematically by the anesthetist who was blinded to the
treatment group.
The postpartum care for both groups was identical and
included monitoring of vital signs (blood pressure, pulse rate,
J Matern Fetal Neonatal Med, Early Online: 1–5
and temperature). Uterine tonus was monitored every 15 min
for 2 h, and then every 4 h. The Foley catheter was removed
on the first postoperative day. The physician staff responsible
for collection of patient reported nausea symptoms were
blinded to group randomization. Examination of the surgi-
cal incision, notation of return of GI function, and a
complete blood count were standard orders for the first
postoperative day.
The primary outcome measured was the rate of antiemetic
drugs required in the postoperative period following cesarean
delivery. Secondary outcome measures included the rate of
PIM. Other outcomes evaluated were nausea and emesis
occurring during the postoperative hospitalization. These
were determined via routine physician assessment of nausea,
emesis, and requirement of antiemetic drugs during the
postoperative period. Return of bowel function was defined as
passage of flatus. Postoperative physicians were blinded to
group assignment to avoid any potential bias; however, the
surgeon who performed the operative procedure cared for
the patient in the postoperative period, thus, was not blinded
to the study group. Postpartum endometritis was defined as a
body temperature greater than 38.5 C with concomitant foul
smelling discharge or abnormally tender uterus on bimanual
examination. Febrile morbidity was defined as an elevated
temperature of 38 C or higher for a minimum of 24 h
following surgery, not associated with lower abdominal or
pelvic tenderness, or other signs of infection. Wound infection
was characterized by partial or total separation of the incision,
as well as the presence of purulent or serous wound discharge
with induration, warmth, and tenderness.
Estimated blood loss was calculated using the difference
in hematocrit values taken before and 48 h after cesarean
delivery, according to the following formula:
Estimated blood loss
0 1
Preoperative hematocrit
B C
Estimated blood volume  @ Postoperative A
hematocrit
¼
Preoperative hematocrit
where the estimated blood volume in milliliters ¼ woman’s
weight in kilograms  85 [15].
All data were recorded and analyzed by another researcher,
who was blinded to the group assignments.
Viney et al. [14] reported that the rate of use of antiemetic
drugs was 18%. Based on this previously reported rate of
antiemetic drug use, a sample size of 215 per group was
required to detect to a 50% difference in the rate of antiemetic
drug use between groups, with a power of 80% and level of
significance of 5%. Chi-squared tests were used to analyze
categorical variables. Student’s t-test and Mann–Whitney’s
U-test were used for continuous variables. The relative risk
(RR), with 95% confidence interval (CI), was calculated.
Statistical significance was set at p50.05.
Results
Between October 2012 and August 2014, 430 patients who
underwent elective cesarean delivery were randomized, with
215 randomized into the control group and 215 randomized
 DOI: 10.3109/14767058.2015.1015415 Saline irrigation at CS 3
Figure 1. Participant flow chart (control Assessed for
group: without irrigation of the abdominal eligibility (n:1835)
cavity; irrigation group: irrigation of the
abdominal cavity using 500 mL of warm
normal saline after closure of the uterine
incision but before closure of the abdominal Excluded (n:1405)
wall). ENROLLMENT
*Refused the parcipitate
(n:55)
430 Randomized *Other reason (n:106)
*Not meeng inclusion
criteria (n:1244)

Allocated control group Allocated irrigaon

(n:215) group (n:215)
ALLOCATION
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Analyzed ( n:215)
Analyzed (n:215) ANALYSIS

nausea and emesis were significantly higher in the irrigation

Table 1. Clinical characteristics of the study groups.
group (26 % and 13 % versus 12.1 % and 5.6 %, p  0.001 and
Control Irrigation p ¼ 0.008). The other postoperative maternal parameters were
group group similar between groups (Table 3).
(n ¼ 215) (n ¼ 215) p value The neonatal outcome variables are reported in Table 4.
Age (years) 28.2 ± 4.7 27.7 ± 4.3 0.233 No between group differences were observed in birth weight,
Parity 1.1 ± 0.6 1.2 ± 0.7 0.507 5-min Apgar scores or neonatal intensive care unit admissions
Gestational age at delivery (weeks) 38.4 ± 0.5 38.5 ± 0.6 0.203 between groups.
Tobacco use 25 (11.6) 22 (10.2) 0.643
Ethanol use 2 (0.9) 2 (0.9) _
Body mass index (kg/m2) 28.2 ± 1.1 28.5 ± 1.0 0.725 Discussion
Gravidity 2.4 ± 0.8 2.4 ± 1.0 0.716
Primary CS 28 (13) 25 (11.6) 0.660 Intra-abdominal irrigation during cesarean delivery for reduc-
Additional medical disease* 36 (16.7) 39 (18.1) 0.703 tion of maternal morbidity is currently an arguable step in
Number of digital examination 1.2 ± 0.5 1.2 ± 0.6 0.749
Number of previous CS
most guidelines and textbooks. The present study demon-
1 136 (72.7) 132 (69.5) 0.486 strated that intra-abdominal irrigation during cesarean deliv-
2 51 (27.3) 58 (30.5) _ ery is associated with high intraoperative and postoperative
nausea and emesis, without any benefit in maternal PIM.
Data are expressed as the mean ± standard deviation or n (%). CS,
cesarean delivery. CS is the most common obstetrical operation worldwide.
*Thyroid disfunction, asthma, etc. Postoperative infectious and febrile morbidity are major
concerns, together with hemorrhage, in this operation. In the
past, irrigation with antibiotics at cesarean delivery has been
into the irrigation group (Figure 1). No difference in maternal evaluated for its impact on PIM [7]. However, in modern
demographics and rate of primary cesarean delivery was times, intravenous antibiotic prophylaxis seems to be more
detected between groups (Table 1). reasonable. Subsequently, irrigation with saline, combined
The rate of intraoperative nausea and emesis was signifi- with the use of intravenous antibiotics, has been evaluated for
cantly higher in the irrigation group (99 and 77, 46 and reduction of PIM [12–14]. Keblawi and Dawley [12] reported
35.8%) than in the control group (58 and 41, 27.0 and 19.1%) that intraperitoneal saline irrigation at the time of CS did not
(p  0.001). No significant differences were identified in the change the postoperative white blood cell and analgesia
estimated blood loss (p ¼ 0.195), operative time (p ¼ 0.476), requirement. Later, Harrigill et al. [13] reported that intra-
and rate of adhesiolysis (p ¼ 0.440) between groups. abdominal irrigation with normal saline at the time of
Furthermore, the rate of intraoperative vessel and bladder cesarean delivery did not appreciably impact PIM, GI
injury were similar between groups (Table 2). recovery, or blood count parameters. The present study
Postoperative outcomes are shown in Table 3. The rate of identified similar findings to these previous studies in PIM.
antiemetic drugs required by patients was significantly higher The incidence of intra and postoperative nausea and
in the irrigation group when compared with the control group emesis is variable and reported to be up to 60% [16,17]. Only
(15.8% versus 8.4%, p ¼ 0.018). Moreover, postoperative one study has examined the effect of saline peritoneal
 4 O. Temizkan et al. J Matern Fetal Neonatal Med, Early Online: 1–5

Table 2. Comparison of the intraoperative surgical outcomes between groups.

Control group Irrigation group

(n ¼ 215) (n ¼ 215) p value RR (95% CI)
Estimated blood loss (mL) 817 ± 320 858 ± 338 0.195 _
Operative time (min) 51.6 ± 12.5 50.8 ± 9.9 0.476 _
Adhesiolysis 52 (24.2) 59 (27.4) 0.440 0.8 (0.6–1.2)
Intraoperative nausea 58 (27.0) 99 (46.0) 50.001 0.5 (0.4–0.7)
Intraoperative emesis 41 (19.1) 77 (35.8) 50.001 0.5 (0.3–0.7)
Uterine vessels injury 2 (0.9) 2 (0.9) _
Bladder injury 3 (1.4) 2 (0.9) 0.653 1.5 (0.2–8.8)

Data are expressed as the mean ± standard deviation or n (%).

Table 3. Comparison of the postoperative outcomes between groups.

Control group Irrigation group

(n ¼ 215) (n ¼ 215) p value RR (95% CI)
Postoperative use of antiemetic 18 (8.4) 34 (15.8) 0.018 0.5 (0.3–0.9)
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Postoperative nausea 26 (12.1) 56 (26.0) 50.001 0.4 (0.3–0.7)

Postoperative emesis 12 (5.6) 28 (13.0) 0.008 0.4 (0.2–0.8)
Postpartum endometritis 28 (13) 26 (12.1) 0.771 1.0 (0.6–1.7)
Febril morbidity 60 (27.9) 46 (21.4) 0.117 1.3 (0.9–1.8)
Postoperative urinary infection 53 (24.4) 49 (22.8) 0.650 1.0 (0.7–1.5)
Wound infection 2 (0.9) 1 (0.5) 0.562 2.0 (0.1–21)
Passage of flatus (day) 1.1 ± 0.2 1.0 ± 0.3 0.615 _
Stool extraction (day) 2.0 ± 0.3 2.1 ± 0.4 0.475 _

Data are expressed as the mean ± standard deviation or n (%).

Table 4. Findings related to neonatal outcome. to peritoneal irritation from the peritoneal saline irrigation.
Also Viney et al. [14] reported that postoperative nausea,
Control Irrigation
group group
emesis, and requirement rate of antiemetic drugs required
Neonatal outcome (n ¼ 215) (n ¼ 215) p value RR (CI 95%) were similar between groups. These findings differed from
the present study. In the present study, postoperative GI
Birth weight (g) 3314 ± 457 3372 ± 374 0.150 _
5-min Apgar 3 2 (0.9) 2 (0.9) _ _ outcomes, such as emesis, nausea, and requirement rate of
NICU admission 1 (0.5) 2 (0.9) 0.562 0.5 (0.04–5.4) antiemetic drug were significantly higher in the irrigation
group than those in the control group, resulting in impaired
Data are expressed as the mean ± standard deviation or n (%). NICU,
neonatal intensive care unit.
postoperative patient comfort. This finding was attributed to
the insufficient drainage of saline from abdominal cavity
intraoperatively, with residual saline resulting in peritoneal
irrigation on intraoperative nausea and vomiting. Viney et al. irritation. Furthermore, no significant differences were
[14] evaluated the effect of intraoperative irrigation on detected in neonatal outcomes between groups. Only
intraoperative nausea and vomiting and postoperative return Harrigill et al. [13] has evaluated neonatal outcomes with
of bowel function after cesarean delivery. However, the study saline irrigation, and they found similar findings to the
did not include an adequate sample size to detect differences. present study.
Furthermore, in that study, the type of anesthesia during CS On one hand, the present study had several strengths. It
was not specified. Intraoperative nausea and emesis can be was a large prospective randomized investigation that
impacted by the anesthetic technique, as well as visceral included an adequate sample size. This investigation was
irritation. Therefore, the present study was designed as a conducted in a tertiary referral center in western Turkey.
prospective clinic trial with sufficient patient numbers, with Furthermore, there were similar demographic and pregnancy
all patients undergoing regional anesthesia. The primary profiles between groups. Experienced obstetricians performed
outcome was the rate of antiemetic drug use required in the all cesarean deliveries, and the average blood loss was
postoperative period, because postoperative patient comfort evaluated using an objective method. In addition, all cesarean
especially during early breastfeeding time was considered deliveries were performed under regional anesthesia. On the
important. other hand, the present study had several limitations. The
Viney et al. [14] reported that irrigation at the time of primary limitation was that only elective CS was included,
cesarean delivery increases intraoperative nausea, without and high-risk patients, such as those with corioamnionitis,
beneficial effects on maternal infectious morbidity. The HELLP syndrome, pre-eclampsia, and abnormal placentation,
present study results were similar to the intraoperative were excluded. Furthermore, there was potential for bias in
findings reported in that previous study. This was attributed determining intra and postoperative outcomes. However, the
 DOI: 10.3109/14767058.2015.1015415
clinical study was designed such that the study participants,
anesthetist, postpartum physician staff, and data analyzer
were blinded to the treatment arm, minimizing bias in data
collection.
In conclusion, the present study demonstrates that irriga-
tion at the time of CS increases both intraoperative and
postoperative nausea and vomiting, without any beneficial
effects on maternal PIM. In the light of these findings, routine
use of saline irrigation in the abdominal cavity does not seem
to be reasonable. Larger studies, involving subjects undergo-
ing emergency CS or in high-risk patients, are necessary to
confirm these findings.
Acknowledgements
We gratefully acknowledge the investigators, coinvestigators,
study coordinators, and the patients who participated in
this trial.
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Declaration of interest
The authors report that they have no conflicts of interest. This
work was supported by departmental funds only.
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