A randomized controlled study investigating the necessity of routine cervical dilatation during elective cesarean section. Preinduction cervical ripening: prostaglandin E2 gel vs hygroscopic mechanical dilator. Is routine cervical dilatation necessary during elective caesarean section? A randomised controlled trial.
To investigate if it was necessary to dilate the cervix routinely during elective cesarean section and to determine the effects of this traditional maneuver on maternal morbidity.
                A total of 150 patients meeting eligibility criteria were enrolled in this prospective, randomized controlled study. Patients were allocated randomly into cervical dilatation group or non-dilated group. In the cervical dilatation group, the surgeon performed cervical dilatation by inserting a double-gloved index finger into the cervical canal of the patients after extraction of placenta and membranes. Endometrial cavity thickness of the patients at postoperative 24 h, development of postoperative febrile-infectious morbidity and postoperative hemoglobin levels were evaluated and compared between the groups.
                The two groups were comparable with regard to demographic and clinical properties. Mean postoperative endometrial cavity thickness of the dilated group was significantly less than the non-dilated group (6.87 ± 2.50, 9.51 ± 3.35 respectively, p < 0.0001). The level of hemoglobin reduction was comparable between the groups (p = 0.37). Febrile morbidity was seen in one patient in the dilated group. Endometritis or wound infection was not encountered in either group during the puerperium.
                Cervical dilatation seems to be an unnecessary intervention during the cesarean section. To evaluate the efficacy and safety of hygroscopic mechanical dilators (Dilapan) for ripening the pregnant cervix prior to induction of labour at or near term and to compare it with an intracervical PGE2 gel (Prepidil).
                One hundred and eighty-five women (69 nulliparae, 116 multiparae) at term with singleton pregnancies in cephalic presentation, who were scheduled for induction of labour in the labour ward at the National University Hospital, but had an unfavourable cervical score were randomized into 2 groups by random number table. In group 1 (Prepidil), 0.5 mg of PGE2 in 2.5 ml of triacetin gel was inserted into the endocervical canal. In women in group 2 (Dilapan) upto a maximum of 4 hygroscopic dilators were placed in the endocervical canal. If labour did not ensue at the end of 12 hours of ripening, the cervical score was assessed, amniotomy was performed and oxytocin commenced. Neonatal and obstetric outcome was compared, statistical analysis performed using Chi-square, and t-tests.
                Significantly more women in the group who received Dilapan for cervical ripening required amniotomy and oxytocin for induction of labour > 12 hours after priming compared with the group who received Prepidil (p < 0.001). Operative delivery for no progress and fetal distress respectively was similar in the 2 groups. The number of cases of hyperstimulation were higher in the Prepidil group but did not result in an increased incidence of operative deliveries for fetal distress. There was one neonatal death and one case of neonatal sepsis in the Dilapan group. Uterine rupture occurred in 1 woman who received Prepidil.
                Dilapan, a mechanical method of cervical ripening is as effective as the more widely accepted mode of ripening with an endocervical PGE2 gel in achieving vaginal delivery. Dilapan would be useful for cervical priming prior to induction of labour in places where prostaglandins are not available because of cost and the need for a cold chain. The purpose of this prospective randomised study was to determine the effect of routine cervical dilatation during elective caesarean section on maternal morbidity.
                Participants with indication for elective caesarean section were randomly allocated to two groups. Group A (n = 200) women with intraoperative cervical dilatation; group B (n = 200) women with no intraoperative cervical dilatation.
                No demographic differences were observed between groups. There was no significant difference between groups in infectious morbidity (P = 0.87) (relative risk (RR) 1.11, 95% confidence interval (CI) 0.58-2.11), endometritis (P = 0.72) (RR 1.68, 95% CI 0.39-7.14), febrile morbidity (P = 0.66) (RR 1.21, 95% CI 0.51-2.87), wound infection (P = 0.82) (RR 1.11, 95% CI 0.44-2.81), endometritis (P = 0.72) (RR 1.68, 95% CI 0.39-7.14) or urinary tract infection (P = 1.00) (RR 1.00, 95% CI 0.28-3.50), and estimated blood loss (P = 0.2). However, group A had longer operative times compared with the group B (P = 0.01).
                Intraoperative digital cervical dilatation during elective caesarean section did not reduce blood loss and postoperative infectious morbidity. The routine digital cervical dilatation during elective caesarean section is not recommended.
There was insufficient evidence of mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity. Further randomised controlled trials with adequate methodological quality comparing intraoperative cervical dilatation using a finger, sponge forceps or other instrument during non-labour caesarean section versus no mechanical dilatation for reducing postoperative morbidity are needed.