Comparative Analysis of Uterine Exteriorization Versus in Situ Repair During Caesarean Section at a Tertiary Care Center

Background: Uterine repair during caesarean section can be performed either after exteriorization of the uterus or in situ. Each technique has potential advantages and disadvantages with respect to operative efficiency, blood loss, postoperative pain, and maternal morbidity. Objectives: To compare intraoperative parameters (blood loss, uterine closure time, changes in vitals, nausea/vomiting, analgesic requirement) and postoperative maternal outcomes (pain scores, complications, hemoglobin drop, hospital stay) between uterine exteriorization and in situ repair. Methods: This prospective comparative analytical study was conducted between July 2023 and June 2025 at a tertiary care hospital. Five hundred women undergoing caesarean section under spinal anaesthesia were randomized into two equal groups: Group A (uterine exteriorization, n = 250) and Group B (in situ repair, n = 250). Intraoperative and postoperative parameters were recorded and analyzed using independent t-tests and chi-square tests. Results: Uterine closure time was significantly shorter in the exteriorization group (11.26 ± 2.18 vs. 13.45 ± 3.89 minutes, p = 0.001), and mean blood loss was lesser (755.8 ± 60.6 vs. 792.4 ± 51.7 mL, p< 0.001). Hemoglobin decline was smaller with exteriorization (1.95 vs. 2.68 g/dL, p< 0.001). However, postoperative analgesic requirement was higher (20.4% vs. 10.8%, p = 0.03). No significant differences were observed between groups in febrile morbidity, surgical site infection, endomyometritis, return of bowel activity, or hospital stay (5.51 ± 2.26 vs. 5.81 ± 2.19 days, p = 0.081). Conclusion: From our study, Uterine exteriorization during caesarean section is a better option as it offers intraoperative advantages of shorter closure time, reduced blood loss, and smaller hemoglobin decline but is associated with increased postoperative pain. Uterine exteriorization gives additional surgical benefits like easy uterine massage, easy access to pouch of douglas, ease of uterine artery ligation/ B- lynch sutures, identification of uterine anomalies, less risk of bowel injury, easy suturing of uterine tears/ extension in lower uterine segment, less risk of missing haematoma and better visualization of posterior uterine wall pathology like fibroid/ endometriosis. In situ repair provides greater postoperative comfort. Both techniques showed similar outcomes for febrile morbidity, surgical site infection, endomyometritis, bowel recovery and hospital stay. Both techniques are safe and the choice should be individualized based on surgeon’s expertise, the intraoperative field and patient specific factors.