Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity?

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Home opioid use following cesarean delivery: How many opioid tablets should obstetricians prescribe?

AIM

To quantify home opioid use after cesarean delivery and identify factors associated with increased opioid use.

METHODS

A convenience sample of women discharged by postoperative day 2 following a term cesarean delivery of a singleton fetus from May 2015 to May 2016 were contacted 2 weeks post-partum and questioned regarding opioid use, pain control and pain expectations.

RESULTS

Among 141 women included in the analysis, the median number of opioid tablets used was 36 (interquartile range 16-45) and the median number prescribed was 60 (interquartile range 42-65). Logistic regression identified operative time ≥59.5 min and number of opioid tablets prescribed as two factors independently associated with opioid use in the top quartile.

CONCLUSION

In the first 2 weeks post-partum, 75% of women used 45 or fewer opioid tablets. Operative time over 1 h and increased number of opioid tablets prescribed are factors associated with higher post-partum opioid use.

Comparison of the Joel-Cohen-based technique and the transverse Pfannenstiel for caesarean section for safety and effectiveness: A systematic review and meta-analysis

Background: Caesarean section (C-section) is the most common surgery among women worldwide, and the global rate of this surgical procedure has been continuously rising. Hence, it is significantly crucial to develop and apply highly effective and safe caesarean section techniques. In this review study, we aimed at assessing the safety and effectiveness of the Joel-Cohen-based technique and comparing the results with the transverse Pfannenstiel incision for C-section. Methods: In this study, various reliable databases such as the PubMed Central, COCHRANE, DARE, and Ovid MEDLINE were targeted. Reviews, systematic reviews, and randomized clinical trial studies comparing the Joel-Cohen-based technique and the transverse Pfannenstiel incision were selected based on the inclusion criteria. Selected studies were checked by 2 independent reviewers based on the inclusion criteria, and the quality of these studies was assessed. Then, their data were extracted and analyzed. Results: Five randomized clinical trial studies met the inclusion criteria. According to the exiting evidence, statistical results of the Joel-Cohen-based technique showed that this technique is more effective compared to the transverse Pfannenstiel incision. Metaanalysis results of the 3 outcomes were as follow: operation time (5 trials, 764 women; WMD -9.78; 95% CI:-14.49-5.07 minutes, p<0.001), blood loss (3 trials, 309 women; WMD -53.23ml; 95% -CI: 90.20-16.26 ml, p= 0.004), and post-operative hospital stay (3 trials, 453 women; WMD -.69 day; 95% CI: 1.4-0.03 day, p<0.001). Statistical results revealed a significant difference between the 2 techniques. Conclusion: According to the literature, despite having a number of side effects, the Joel-Cohen-based technique is generally more effective than the Pfannenstiel incision technique. In addition, it was recommended that the Joel-Cohen-based technique be used as a replacement for the Pfannenstiel incision technique according to the surgeons' preferences and the patients' conditions.

Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon's experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: "acute pain", "chronic pain", "Pfannenstiel incision", "Misgav-Ladach", "Joel Cohen incision", in combination with "Caesarean Section", "abdominal incision", "numbness", "neuropathic pain" and "nerve entrapment". Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.

Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis

A systematic review and metaanalysis were performed through electronic database searches to estimate the effect of uterine closure at cesarean on the risk of adverse maternal outcome and on uterine scar evaluated by ultrasound. Randomized controlled trials, which compared single vs double layers and locking vs unlocking sutures for uterine closure of low transverse cesarean, were included. Outcomes were short-term complications (endometritis, wound infection, maternal infectious morbidity, blood transfusion, duration of surgical procedure, length of hospital stay, mean blood loss), uterine rupture or dehiscence at next pregnancy, and uterine scar evaluation by ultrasound. Twenty of 1278 citations were included in the analysis. We found that all types of closure were comparable for short-term maternal outcomes, except for single-layer closure, which had shorter operative time (-6.1 minutes; 95% confidence interval [CI], -8.7 to -3.4; P < .001) than double-layer closure. Single layer (-2.6 mm; 95% CI, -3.1 to -2.1; P < .001) and locked first layer (mean difference, -2.5 mm; 95% CI, -3.2 to -1.8; P < .001) were associated with lower residual myometrial thickness. Two studies reported no significant difference between single- vs double-layer closure for uterine dehiscence (relative risk, 1.86; 95% CI, 0.44-7.90; P = .40) or uterine rupture (no case). In conclusion, current evidence based on randomized trials does not support a specific type of uterine closure for optimal maternal outcomes and is insufficient to conclude about the risk of uterine rupture. Single-layer closure and locked first layer are possibly coupled with thinner residual myometrium thickness.

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes

BACKGROUND

Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed.

OBJECTIVES

The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 November 2013).

SELECTION CRITERIA

Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy.

MAIN RESULTS

A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layersSixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfacesThree trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layersThe two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed.There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured.

AUTHORS' CONCLUSIONS

There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation post-caesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed.

Surgical techniques for uterine incision and uterine closure at the time of caesarean section

BACKGROUND

Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.

OBJECTIVES

To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and healthcare resource use.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2013) and reference lists of all identified papers.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently.

MAIN RESULTS

Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and only six trials indicating blinding of outcome assessors.Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.38 to 2.20).Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving 2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies; 1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69), the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant differences identified for the limited outcomes reported.A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI 0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37 to 0.89).Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the meta-analyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau² = 0.15; I² = 49%), or other reported clinical outcomes.

AUTHORS' CONCLUSIONS

Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques, short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques they prefer and currently use.

Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial

OBJECTIVE

This study was designed to compare the Pfannenstiel versus Joel-Cohen incisions during caesarean deliveries.

MATERIAL AND METHODS

Women undergoing caesarean deliveries (n=153) were randomly assigned to the conventional Pfannenstiel or the Joel-Cohen incision. The outcome measures included postoperative pain, requirement for analgesics, operative time and other postoperative data.

RESULTS

Maternal age, parity, gestational age and indications for caesarean delivery were similar across groups. Total operative time, postoperative recovery duration, time to get out of bed, to walk straight without support, to detect audible intestinal sounds and to pass gases or stools were shorter in the Joel-Cohen group. Postoperative haematocrit decreases and estimated intraoperative blood loss were similar between the two techniques. Moderate and severe pain at 6, 12 and 18 hours postoperatively was less frequent after the Joel-Cohen technique.

CONCLUSION

Joel-Cohen incision in the non-scarred abdomen may provide a faster technique for caesarean section with less postoperative pain and probably early postoperative recovery in our circumstances.

Abdominal surgical incisions for caesarean section

BACKGROUND

Caesarean section is the commonest major operation performed on women worldwide. Operative techniques, including abdominal incisions, vary. Some of these techniques have been evaluated through randomised trials.

OBJECTIVES

To determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013).

SELECTION CRITERIA

Randomised controlled trials of intention to perform caesarean section using different abdominal incisions.

DATA COLLECTION AND ANALYSIS

We extracted data from the sources, checked them for accuracy and analysed the data.

MAIN RESULTS

Four studies (666 women) were included in this review.Two studies (411 women) compared the Joel-Cohen incision with the Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative febrile morbidity (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.14 to 0.87) with the Joel-Cohen incision. One of the trials reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40 to 0.76); operating time (mean difference (MD) -11.40, 95% CI -16.55 to -6.25 minutes); delivery time (MD -1.90, 95% CI -2.53 to -1.27 minutes); total dose of analgesia in the first 24 hours (MD -0.89, 95% CI -1.19 to -0.59); estimated blood loss (MD -58.00, 95% CI -108.51 to -7.49 mL); postoperative hospital stay for the mother (MD -1.50, 95% CI -2.16 to -0.84 days); and increased time to the first dose of analgesia (MD 0.80, 95% CI 0.12 to 1.48 hours) compared with the Pfannenstiel group. No other significant differences were found in either trial.Two studies compared muscle cutting incisions with Pfannenstiel incision. One study (68 women) comparing Mouchel incision with Pfannenstiel incision did not contribute data to this review. The other study (97 women) comparing the Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50); need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98); wound infection (RR 1.26, 95% CI 0.27 to 5.91); physical tests on muscle strength at three months postoperative and postoperative hospital stay (MD 0.40 days, 95% CI -0.34 to 1.14).

AUTHORS' CONCLUSIONS

The Joel-Cohen incision has advantages compared with the Pfannenstiel incision. These are: less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.

A randomized comparative study on modified Joel-Cohen incision versus Pfannenstiel incision for cesarean section

OBJECTIVE

Pfanennstiel incision is the most commonly used incision for cesarean section, but may not be the best. This study compared the modified Joel-Cohen incision with the Pfannenstiel incision to evaluate whether techniques to open the abdomen might influence operative time, and maternal and neonatal outcomes.

MATERIAL AND METHODS

In a randomized comparative trial, 302 women with gestational age >34 weeks, requiring cesarean section, were randomly assigned to either modified Joel-Cohen incision or Pfannenstiel incision for entry into the peritoneal cavity. The primary outcome measure was total time required for performing operation and secondary outcome measures were baby extraction time, number of haemostatic procedures used in the abdominal wall, postoperative morbidity, postoperative hospital stay and neonatal outcome.

RESULTS

Mean total operative time was significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group (29.81 vs 32.67 min, p<0.0001, 95%CI=2.253 to 3.467). Time taken to deliver the baby and haemostatic procedures required during operation were also significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group. Requirement of strong analgesics was higher in the Pfannenstiel group (53.64% vs 21.85%, p<0.0001). There was no statically significant difference in the incidence of postoperative wound complications but postoperative stay in hospital was significantly less in the modified Joel-Cohen group (p=0.002). Neonatal outcomes were similar in both groups.

CONCLUSION

The modified Joel-Cohen incision for entry into peritoneal cavity during cesarean section is associated with reduced mean total operative and baby extraction times with less postoperative pain and shorter hospital stay, which may be beneficial and cost effective.

Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions

OBJECTIVE

To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation.

DESIGN

A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section.

SETTING

Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.

POPULATION

One hundred and twenty-seven pregnant women undergoing first repeat caesarean section.

METHODS

Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression.

MAIN OUTCOME MEASURE

Prevalence rate of pelvic and abdominal adhesions.

RESULTS

Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions.

CONCLUSIONS

Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.

Techniques for cesarean section

The effects of complete methods of cesarean section (CS) were compared. Metaanalysis of randomized controlled trials of intention to perform CS using different techniques was carried out. Joel-Cohen-based CS compared with Pfannenstiel CS was associated with reduced blood loss, operating time, time to oral intake, fever, duration of postoperative pain, analgesic injections, and time from skin incision to birth of the baby. Misgav-Ladach compared with the traditional method was associated with reduced blood loss, operating time, time to mobilization, and length of postoperative stay for the mother. Joel-Cohen-based methods have advantages compared with Pfannenstiel and traditional (lower midline) CS techniques. However, these trials do not provide information on serious and long-term outcomes.

Surgical techniques for uterine incision and uterine closure at the time of caesarean section

BACKGROUND

Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.

OBJECTIVES

To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and health care resource use.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently.

MAIN RESULTS

We identified 30 studies, of which 15 (3972 women) were included. Ten trials compared single layer uterine closure with double layer uterine closure (2531 women), two trials compared blunt with sharp dissection at the time of the uterine incision (1241 women), and two trials compared auto-suture devices with traditional hysterotomy (300 women). Blunt dissection was associated with a reduction in mean blood loss at the time of the procedure when compared with sharp dissection of the uterine incision (one study, 945 women, mean difference (MD) -43.00, 95% confidence interval (CI) -66.12 to -19.88). There was no statistically significant difference related to need for blood transfusion (one study, 945 women, risk ratio (RR) 0.22, 95% CI 0.05 to 1.01). The use of an auto-suture instrument when compared with traditional methods of hysterotomy was associated with no difference in the amount of blood loss during the procedure (one study, 200 women, MD -87.00, 95% CI -175.09 to 1.09), but a statistically significant increase in the duration of the procedure (one study, 197 women, MD 3.30, 95% CI 0.02 to 6.62). Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss (three studies, 527 women, MD -70.11, 95% CI -101.61 to -38.60); duration of the operative procedure (four studies, 645 women, MD -7.43, 95% CI -8.41 to -6.46); and presence of postoperative pain (one study, 158 women, RR 0.69, 95% CI 0.52 to 0.91).

AUTHORS' CONCLUSIONS

While caesarean section is a common procedure performed on women worldwide, there is little information available to inform the most appropriate surgical technique to adopt.

Comparison between the use of the Joel-Cohen incision and its modification during Stark's cesarean section

OBJECTIVE

A comparative evaluation between the Joel-Cohen incision and its modification for the Stark's cesarean section (CS).

MATERIALS AND METHODS

In a retrospective study, 477 women who underwent a Stark's CS were evaluated: 204 with the Joel-Cohen incision (JC) and 273 with a modified Joel-Cohen incision (MJC). All patients were checked for the following parameters: febrile morbidity, the need for painkillers, duration of hospital stay, and ultrasound examination for blood collection (BC) on the third postoperative day. The collections, when diagnosed were divided into three groups: (1) in the abdominal wall, (2) in the pouch of Douglas, and (3) in the lower uterine segment (LUS). Those included in the study were low-risk primiparae at term, presenting for CS for breech presentation, macrosomia, and on demand, and who had combined spinal-epidural anesthesia. Statistical evaluation was performed using SAS/V12 software.

RESULTS

There were no statistical differences between the two groups with regard to febrile morbidity, duration of need for painkillers, and hospital stay. Statistically more blood collections were found in the MJC incision group (5.4% in the abdominal wall, 12.4% in the pouch of Douglas, and 11.7% in the LUS) than in the classical JC incision group (3.9% in the abdominal wall, 10.2% in the pouch of Douglas, and 8.8% in the LUS), however without any clinical significance.

CONCLUSIONS

The routine use of the classical JC incision during the Stark's CS seems to be more rational, and causes fewer blood collections.

Techniques for caesarean section

BACKGROUND

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique.

OBJECTIVES

To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers.

SELECTION CRITERIA

Randomised controlled trials of intention to perform caesarean section using different techniques.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data.

MAIN RESULTS

'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes).

AUTHORS' CONCLUSIONS

'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

Abdominal surgical incisions for caesarean section

BACKGROUND

Caesarean section is the commonest major operation performed on women worldwide. Operative techniques, including abdominal incisions, vary. Some of these techniques have been evaluated through randomised trials.

OBJECTIVES

To determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2006).

SELECTION CRITERIA

Randomised controlled trials of intention to perform caesarean section using different abdominal incisions.

DATA COLLECTION AND ANALYSIS

We extracted data from the sources, checked them for accuracy and analysed the data.

MAIN RESULTS

Four studies were included in this review. Two studies (411 participants) compared the Joel-Cohen incision with the Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative morbidity (relative risk (RR) 0.35, 95% confidence interval (CI) 0.14 to 0.87) with the Joel-Cohen incision. One of the trials reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40 to 0.76); operating time (weighted mean difference (WMD) -11.40, 95% CI -16.55 to -6.25 minutes); delivery time (WMD -1.90, 95% CI -2.53 to -1.27); total dose of analgesia in the first 24 hours (WMD -0.89, 95% CI -1.19 to -0.59); estimated blood loss (WMD -58.00, 95% CI -108.51 to - 7.49 ml); postoperative hospital stay for the mother (WMD -1.50, 95% CI -2.16 to -0.84); and increased time to the first dose of analgesia (WMD 0.80, 95% CI 0.12 to 1.48) compared to the Pfannenstiel group. No other significant differences were found in either trial. Two studies compared muscle cutting incisions with Pfannenstiel incision. One study (68 women) comparing Mouchel incision with Pfannenstiel incision did not contribute data to this review. The other study (97 participants) comparing the Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50); need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98); wound infection (RR 1.26, 95% CI 0.27 to 5.91); physical tests on muscle strength at three months postoperative and postoperative hospital stay (WMD 0.40 days, 95% CI -0.34 to 1.14).

AUTHORS' CONCLUSIONS

The Joel-Cohen incision has advantages compared to the Pfannenstiel incision. These are less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.

Uterine rupture during VBAC trial of labor: risk factors and fetal response

For the woman with a prior uterine scar, neither repeat elective cesarean birth nor vaginal birth after cesarean birth (VBAC) trial of labor (TOL) is risk-free. When VBAC-TOL is successful, it is associated with less morbidity than repeat cesarean birth. However, when VBAC-TOL fails due to uterine rupture, severe consequences often ensue. The challenge for clinicians today is to provide women who desire TOL after cesarean birth, a more individualized risk assessment of uterine rupture, thereby enhancing success and optimizing outcome. This article examines major risk factors for uterine rupture during VBAC-TOL. In addition, fetal response to uterine rupture and neonatal outcomes are reviewed.

Closure versus non-closure of the peritoneum at caesarean section

BACKGROUND

Caesarean section is a very common surgical procedure world wide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or not.

OBJECTIVES

The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intra-operative, immediate and long-term postoperative and long-term outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (November 2002).

SELECTION CRITERIA

Controlled trials comparing leaving the visceral and/or parietal peritoneum unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by two reviewers.

MAIN RESULTS

Nine trials involving 1811 women were included and analysed. The methodological quality of the trials was variable. Non-closure of the peritoneum reduced operating time whether both or either layer was not sutured. For both layers, the operating time was reduced by 7.33 minutes, 95% confidence interval (CI) -8.43 to -6.24. There was significantly less postoperative fever and reduced postoperative stay in hospital for visceral peritoneum and for both layer non-closure. There were no other statistically significant differences. The trend for analgesia requirement and wound infection tended to favour non-closure, while endometritis results were variable. Long-term follow up in one trial showed no significant differences. The power of the study to show differences was low.

REVIEWER'S CONCLUSIONS

There was improved short-term postoperative outcome if the peritoneum was not closed. Long-term studies following caesarean section are limited, but data from other surgical procedures are reassuring. There is at present no evidence to justify the time taken and cost of peritoneal closure.

The impact of a single-layer or double-layer closure on uterine rupture

OBJECTIVE

Our purpose was to measure the impact of a single-layer or double-layer closure on uterine rupture at subsequent delivery.

STUDY DESIGN

This is an observational cohort study of all women undergoing a trial of labor from 1988 to 2000 in a tertiary care center, after a single low transverse cesarean delivery. Factors most highly associated with uterine rupture were identified by using univariate regression analysis. Multivariate logistic regression analysis was used to adjust for selected confounding variables.

RESULTS

Of the 2142 women who met the study criteria, 1980 (92.4%) had maternal records and original operative reports reviewed. After adjustments were made for confounding variables, the odds ratio for uterine rupture in women with a single-layer closure was 3.95 (95% CI, 1.35-11.49).

CONCLUSION

A single-layer closure of the previous lower segment incision was the most influential factor and was associated with a 4-fold increase in the risk of uterine rupture compared with a double-layer closure.