Comparative study to assess the outcome of omitting bladder flap formation from caesarean delivery


  • Pratiksha Gupta Department of Obstetrics and Gynecology, ESI, PGIMSR, Basaidarapur, New Delhi, India
  • Suman Kumari Department of Obstetrics and Gynecology, ESI, PGIMSR, Basaidarapur, New Delhi, India



BF (bladder flap), CS (caesarean section), RCT (randomised control trial)


Background: The aim of this study is to evaluate the effects of omitting the step of bladder flap formation at lower-segment caesarean delivery.

Methods: It is a RCT (randomised control trial), non-blinded study conducted in a tertiary care hospital. A total of 104 women who underwent caesarean delivery (elective or emergency) were prospectively randomized to one of the two groups. In the study group (n= 54), caesarean was performed without formation of a bladder flap. In the control group (n=50), caesarean was performed with the formation of a bladder flap before the uterine incision.

Results: There were differences of median skin incision to delivery interval (5 versus 6.5 minutes, P <0.0001), median total operating time (35 versus 44.5 minutes, P 0.0002), and median blood loss (haemoglobin 0.5 versus 1g/dl, P 0.0001) in favor of the study group. Postoperative incidence of urinary tract infection was reduced in the study group (1% versus 9%, P <0.0006) and bowel function returned early in the study group (day 2 versus 3, P<0.0001).  Bladder flap formation step was successfully omitted in (11/18, 61.11%) of previous CS (caesarean section) patients in the study group and (7/12, 58.33%) in control group illustrating that unless required, BF (bladder flap) formation step can even be omitted in previous CS patients.

Conclusions: Omission of the bladder flap provides short term advantages such as reduction of total operating time, incision-delivery interval, and reduced blood loss and that this technique can even be applied in previous caesarean section patients.


Dumont A, de Bernis L, Bouvier-Colle MH, Breart G. Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review. Lancet. 2001;358:1328-33.

Murray SF, Pradenas FS. Health sector reform and rise of caesarean birth in Chile. Lancet. 1997;349:64.

Pai M, Sundaram P, Radhakrishnan KK, Thomas K, Muliyil JP. A high rate of caesarean sections in an affluent section of Chennai: is it cause for concern? Natl Med J India. 1999;12:156-8.

International Institute for Population Sciences (IIPS) and Ministry of Health and Family Welfare. National Family Health Survey-4 (NFHS-4), India-Factsheet.

International Institute for Population Sciences (IIPS) and Macro International 2007. National Family Health Survey-3 (NFHS-3), 2005-2006: India: Volume 1, Mumbai.

Malvasi A, Tinelli A, Gustapane S, Mazzone E, Cavallotti C, Stark Jr M, et al. Surgical technique to avoid bladder flap formation during cesarean section. G Chir. 2011;32(11/12):498-503.

Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesarean necessary? A randomized trial. Obstet Gynecol. 2011;98(6):1089-92.

Malvasi A, Tinelli A, Guido M, Cavallotti C, Dell’Edera D, Zizza A, et al. Effect of avoiding bladder flap formation in cesarean section on repeat cesarean delivery. Eur J Obstet Gynecol Reprod Biol. 2011;159(2):300-4.

Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section. Cochrane Database Syst 5 Rev. 2003;CD000163.

Lev-Toaff AS, Baka JJ, Toaff ME, Friedman AC, Radecki PD, Caroline DF. Diagnostic imaging in puerperal febrile morbidity. Obstet Gynecol. 1991;78:50-5.

Faustin D, Minkoff H, Schaffer R, Crombleholme W, Schwarz R. Relationship of ultrasound findings after caesarean section to operative morbidity. Obstet Gynecol. 1985;66:195-8.

Faricy PO, Augspurger RR, Kaufman JM. Bladder injuries associated with cesarean section. J Urol. 1978;120(6):762-3.

Pelosi MA 2nd, Pelosi MA 3rd. Risk factors for bladder injury during cesarean delivery. Obstet Gynecol. 2005;105(4):900-1.

Woyton J, Florjanski J, Zimmer M. Nonclosure of the visceral peritoneum during Cesarean sections. Ginekol Pol. 2000;71(10):1250-4.

Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or nonclosure of the visceral peritoneum at cesarean delivery. Am J Obstet Gynecol. 1996;174(4):1366-70.

Pelosi M, Ortega I. Cesarean section: Pelosi’s simpliwed technique. Rev Chil Obstet Gynecol. 1994;59(5):372-7.

Wood R, Simon H. Oz Ali-Utku. Pelosi-Type vs. traditional cesarean delivery. A prospective comparison. J Reprod Med. 1999;44:788-95.

Chigbu C, Ezeome I, Iloabachie G. Non-formation of bladder Xap at cesarean section. Int J Gynaecol Obstet. 2006;95:284-5.

Soper D, Brockwell W, Dalton H. The importance of wound infection in antibiotic failures in the therapy of postpartum endometritis. Surg Gynecol Obstet. 1992;174:256.

Burke J II, Gallup D. Incisions for gynaecologic surgery. In: Rock JA, Jones HW III, eds. Telinde’s operative gynaecology. Lippincott Williams and Wilkins, Philadelphia; 2003:255-290.

Stark M. Technique of cesarean section: the Misgav Ladach method. In: Popkin DR, Peddle L, eds. Women’s health today. prospective on current research and clinical practice. Montreal: Parthenon Publishing Group; 1994:81-85. Proceedings of the XIV FIGO World Congress of Gynecology and Obstetrics, New York London.

Woo GM, Twickler DM, Stettler RW, Erdman WA, Brown CE. The pelvis after cesarean section and vaginal delivery: normal MR findings. Am J Roentgenol. 1993;161:1249-52.

Maldjan C, Adam R, Maldjan J, Smith R. MRI appearance of the pelvis in the post caesarean section patient. Magn Reson Imaging. 1999;17:223-7.






Original Research Articles