H.Muffedi  ( Sobhraj Maternity Hospital, Karachi )
S.Syed  ( Sobhraj Maternity Hospital, Karachi )

The status of maternal health in Pakistan is poor. Each year an estimated 25,000 to 30,000 women die due to pregnancy and related causes. Innumerable number of women suffer from complications, some of which may be severe. This reflects poorly on the status and health care available to pregnant women.1
The tertiary hospitals in public sector providing emergency obstetric care and managing complications are over crowded with a lot of work pressure and limited resources. Caesarean section (C. section) is a frequent obstetrical operation. Supplies of material and requirement for emergency are limited, and the socio-economic condition of patients are also poor. The general health of women giving birth makes limitation of blood loss imperative. Blood is in short supply and transfusion is avoided when ever possible due to the risk of lethal infections.
The Misgav Ladach Method has been adopted in many developed and developing countries. The claimed advantages of Misgav Ladach Method are that it is less traumatic for the mother with quicker post-operative recovery, less febrile reactions, less need for antibiotics, a shorter period before normal bowel function returns, less peritoneal adhesions and less scarring in the abdominal layers. It is said to cause less bleeding in the abdominal wall and is quick so that it can be used for both planned and emergency C. sections. It is also a method easy to learn. These claims have now been tested in a randomized controlled trial.2
It is more economical for health care centres, as well as patients because there is less use of suture material and the patients are discharged earlier with the result that the financial strains and stress on the entire family attending the patient is reduced. It also makes earlier bed availability for the next patients waiting for their turn to be treated in the hospital.
Knowledge about the method was known after the FIGO World Congress of Gynaecology and Obstetrics in Montreal in September 1994. In the following FIGO Congress in August 1997 in Copenhagen, four presentation showed the advantages of the method. At the recent FIGO Congress in September 2000 in Washington there were presentations that showed the advantages of Misgav Ladach method.

A prospective study was conducted at Sobhraj Maternity Hospital, a tertiary referral centre from 1st January 1999 to 31st December 1999. A total of 84 patients were included in this study.
Inclusion criteria were, indications for C. Section and first C. Section both elective or emergency and gestational age >35 weeks. Al patients fulfilling these criteria were included irrespective of whether they were booked, unbooked, referred, with medical disorder and of any age, body weight and parity.

The patients were admitted in the labour room either directly or through the out patient department. In the labour room these patients were seen by doctors and prepared for Caesarean section. There are three operation theatres in Sobhraj Maternity Hospital. The choice of patient selection was according to the turn of patients due to the availability of the theatre, the emergency of the situation and the presence of particular surgeon who was capable of performing this surgery in that theatre. At least 1 pint of blood was cross-matched. Prophylactic antibiotic was given to all patients at the time of induction. Epidural, spinal or general endotracheal anaesthesia was given to the patient at the discretion of attending anaesthetist and consistent with the request of the patient.

A Joel Cohen incision (a straight transverse superficial incision) in the skin about 3cm below the line joining the anterior superior iliac spines about 17cm in length was made and subcutaneous tissue was not disturbed apart from the midline.
A short transverse cut of about 2-3 cm was made through the fat down to the rectus sheath. The transverse incision was enlarged bilaterally underneath with scissors, the fat and subcutaneous tissue without being disturbed. The rectus sheath was separated caudally and cranially using the two index fingers. The rectus muscle was pulled apart, the parietal peritoneum opened with index finger and using a scalpel a transverse superficial incision was made through the visceral peritoneum. The visceral peritoneum and bladder was pushed down using two fingers. A small incision was then made in lower uterine segment with a scalpel and the uterus opened with an index finger and the hole enlarged between the index finger of one hand and the thumb of the other hand. The placenta was removed manually after delivery of the baby. The uterus was closed with a one layer continuous locking stitch. The visceral and parietal peritoneal layers are left open. The rectus sheath was stitched with a continuous non-locking stitch. The skin was closed with two or three mattress sutures. The space in between was opposed with non- traumatic forceps for 5 minutes.3
Statistical analysis was performed with the programme SPSS-8.0 for Windows and the results expressed as mean (SD).

A total of 84 patients were studied. Mean age of the patients at the time of surgery was 36.54 ± 5.23 years, mean weight 66.38 ± 6.84 kg and mean gestational age 38.95 ± 1.66 weeks (Table 1). There were 47 (56%) primipara and 37 (44%) multipara.

Duration of surgery and number of Suture Material used

Minimum duration of surgery was 18 minutes and maximum 40 minutes (mean of 23 ± 4.80 minutes). During surgery minimum number of suture material used were 3 and maximum 5 (mean 3.3 ± 0.48). Minimum blood loss during surgery was 200ml and maximum 800ml (mean 346.6 ± 123ml.
The postoperative pain was studied by noting the number and duration of injectable analgesia used according to the statement of the patient. The mean doses of injectable analgesia used 3.45 ± 5.8 ml and the mean duration of postoperative injectable analgesia 27.61 ± 4.71 hours. Minimum time for the start of oral intake were 8 hours postoperatively and maximum 10 hours. Minimum time for the patient to leave bed after surgery was 2 hours and maximum time 12 hours (mean 16.51 ± 2.4 hours).
Fifty eight patients had their bowel movement (passage of stool) on second postoperative day, 15 patients had postoperative complications, of whom 6 had wound infection, 4 endometritis, 3 postoperative haemorrhage, 1 cystitis and 1 mild intestinal atony. Six patients had wound infection, 2 patients required resuturing due to dehiscence of scar.
Twenty four (28.6%) patients were discharged from the hospital on second postoperative day and 34 (40.5%) on third post-operative day. Patients who had postoperative complications stayed in hospital for a longer period. Four patients (4.8%) stayed for 8 days and 4 (4.8%) for 10 days (Table 2). Mean hospital stay was 3.70 ± 2.14 days. Table 1 .Descriptive statistics

	Age (year)	Gestational aeg(week)	Weight (kg.)
N	84	84	84
Minimum	17.00	36.00	52.00
Maximum	38.00	42.00	86.00
Mean	26.5476	38.9524	66.3810
Standard Deviation	5.2375	1.6640	6.8405

Table 2 . Hospital stay days

Days	Frequency	Percent	Valid Percent	Cumulative Percent
2.00	24	28.6	28.6	28.6
3.00	34	40.5	40.5	69.0
4.00	7	8.3	8.3	77.4
5.00	5	6.0	6.0	83.3
6.00	4	4.8	4.8	88.1
7.00	2	2.4	2.4	90.5
8.00	4	4.8	4.8	95.2
10.00	4	4.8	4.8	100.0
Total	84	100.0	100.0

This was a descriptive study with results giving the outcome of Misgav Ladach method. There would have been a more positive result if a comparative study between the conventional method of caesarean section and Misgav Ladach method was carried out.
In this study patients with previous abdominal (caesarean) surgery, uterine rupture and gestational age less than 35 weeks were excluded. The decision to exclude previous caesarean section was to avoid anticipated technical difficulties encountered with repeated Caesarean sections. This method can also be applied for previous caesarean section even if it was a midline or lower abdominal incision or pfannenstiel incision. Haemorrhage at the time of caesarean section may be related to operative procedure, such as damage to the uterine vessels or incidental due to uterine atony, or placenta previa / accreta. The origin of the excess blood loss is generally apparent at the time of surgery. Exact estimation of blood loss in surgical procedure is difficult. The amount of blood loss was calculated by using the Gravimatric method.. Five patients received blood transfusion during surgery. Restriction of blood loss during surgery is of major importance, since blood transfusion may transmit lethal infections and cause anaphylactic reaction.
The placenta is extracted manually in the Misgav Ladach procedure. Reduction in blood loss has been reported when delivering the placenta spontaneously with gentle traction on the umbilical cord compared with manual extraction. The uterus is exteriorized and compressed while suturing it in the Misgav Ladach procedure. It has been argued that such exteriorization may increase nausea and pain and increase the risk of air embolism whether the uterus is repaired in situ or exteriorized does not affect blood loss, according to Magann et al.4
The reduction in operating time, minimal blood loss and less use of suture material are of major importance for the developing countries. The reduced number of suture material used provides economic advantages and may even determine whether necessary operative procedures can be undertaken in time or not, especially when the supplies are limited. A decrease in operation time also confers economic benefits, and so does reduced bleeding as less number of gauzes and packs were used. The non-closure of both layers of peritoneum and a simple layer of closure of hysterotomy leads to decrease in operation time and less use of the suture material.
The peritoneal defects when left undisturbed, demonstrate mesothelial integrity (reperitonization) by 48 hours and complete indistinguishable healing by 5 days. Adhesions are caused by ischaemia, inflammation and infection rather than by open surfaces.5 Chapman et al.6 followed up 164 of those 906 women in their next delivery reporting that the type of closure (one or two layer) does not significantly effect the outcome of the next pregnancy. No difference was found in length of labour, mode of or incidence of uterine scar dehiscence, chorioamnionitis, postpartum endometritis, haemorrhage, transfusion and abnormal placentation. Non closure of peritoneum has been shown to reduce operating time reduce the need for postoperative analgesics, postoperative febrile morbidity and wound infection and shorten hospital stay.
It is not just the elegancy, efficiency and short duration of operation that are related to the lower morbidity, but also the less damage inflicted on the tissue during the procedure. The new method is easy to learn and quick to perform.
Modifications to the method of caesarean delivery can be made to the advantage of the patient.

The authors acknowledge the support of all senior staff of Sobhraj Maternity Hospital who performed these operations as per protocol. The technical help of Mr. Muhammad Shahid in preparing this manuscript for publication is highly appreciated

1. Women Health in Pakistan: fact sheets prepared for Unicef Pakistan National Forum on Women's Health. 3-5 Nov. 1997.

2. Elisabe TH, Marine-Lousie Nordstr. The Misgav Ladach method for Caesarean Section compared to Pfannensteil method. Acta Obstet Gynaecol Scand 1999;78:37-41.

3. Holmgren G, Shjolor L, Stark M. The Misgav Ladach method for Caesarean Section; method description. Acta Obstet. Gynaecol Scand. 1999;78:615-21.

4. Magnn EF, Dodson MK, Albert JR, et al. Blood loss at time of Caesarean Section method of placental removal and exteriorisation versus in situ repair of the uterine incision. Surg Gynaecol Obstet 1993;177:389-92.

5. Bukman RF, Jr. Buckmann PD, Hufnagel HV, et al. A physiological biases for the adhesion - free healing of deperitonealized surfaces. J Surg Res 1976; 21 67-76.

6. Shelly J, Chapman, Owen J, Hauth JC. One versus two layer closure of a low
transverse caesarean. The next pregnancy Obstet Gynaecol 1997; 89:16-18.