Uterine exteriorization versus in-situ uterine repair during cesarean delivery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND

During cesarean delivery, uterine repair can be performed either with uterine exteriorization or in situ within the abdominal cavity. The optimal technique remains controversial, with inconsistent evidence regarding surgical outcomes and maternal complications.

OBJECTIVES

To evaluate the comparative benefits and harms of uterine exteriorization versus in-situ uterine repair during cesarean delivery with respect to surgical outcomes and maternal complications.

METHODS

We searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov up to May 2026. Randomized controlled trials comparing uterine exteriorization with in-situ uterine repair during cesarean delivery were included. Primary outcomes included estimated blood loss (EBL), intraoperative nausea, vomiting, and hypotension. Random-effects meta-analyses were conducted using mean differences (MD) and risk ratios (RR) with 95% confidence intervals.

RESULTS

Twenty-nine randomized controlled trials including 23,152 participants were analyzed. Uterine exteriorization was associated with lower EBL (MD -42.86 mL; 95% CI -79.78 to -5.95), a smaller postoperative hemoglobin decrease (MD -0.26 g/dL; 95% CI -0.46 to -0.05), and shorter uterine closure time (MD -1.08 min; 95% CI -1.59 to -0.57). However, a higher risk of intraoperative hypotension (RR 1.33; 95% CI 1.02 to 1.74), nausea (RR 1.41; 95% CI 1.16 to 1.72), vomiting (RR 2.25; 95% CI 1.54 to 3.28), and delayed return of bowel function (MD 3.22 h; 95% CI 0.91 to 5.53) was observed.

CONCLUSIONS

Uterine exteriorization and in-situ uterine repair are generally comparable in terms of safety and overall surgical outcomes. While exteriorization may reduce blood loss and uterine closure time, it is associated with increased intraoperative nausea, vomiting, hypotension, and delayed recovery of bowel function.