The more than one million cesarean deliveries done in the United States in 2003 represent more than one fourth of all deliveries—the highest figure to date. Whether or not to close the parietal peritoneum remains in dispute, although nonclosure reportedly has been associated with a shorter operating time and no difference in postoperative pain. Closing only the visceral peritoneum, on the other hand, lengthens operating time and may cause infectious morbidity. The risk of adhesion formation reportedly correlates with closure of the parietal peritoneum, and some clinicians have recommended that it not be closed. The effect of not closing the peritoneum at initial section on the risk of adhesions at a subsequent cesarean delivery was evaluated in a prospective cohort study of women having their first repeat cesarean section in the years 1996–2003. The parietal peritoneum was left open at initial surgery in 106 women and was closed in 67 others. More white women had closure, but there were no significant group differences in age, gestational diabetes, past infection, or previous labor.
Patients having closure of the parietal peritoneum at initial cesarean section had significantly fewer dense and filmy adhesions than when it was not closed (52% vs 73%). This effect held for adhesions between the omentum and fascia, omentum and uterus, and fascia and uterus. The risk of bowel adhesions did not differ significantly. Similar results were observed when only dense adhesions were analyzed. On multivariable logistic regression analysis, the odds ratio (OR) for dense and filmy adhesions at repeat cesarean delivery in women having peritoneal closure initially was 0.20 (95% confidence interval (CI), 0.08–0.49). The OR for dense adhesions only was 0.32 (95% CI, 0.13–0.79). Closure did not significantly alter operating time at the second cesarean delivery, but it did delay the return of bowel function.
These findings from a nonrandomized study bring into question the practice of not closing the parietal peritoneum at cesarean delivery.