Systematic reviewsObstetricsEvidence-based surgery for cesarean delivery: an updated systematic review
Section snippets
Materials and methods
This review was modeled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.5 We performed an English-language MEDLINE, PubMed, and COCHRANE database search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials plus each technical aspect of the operation (eg, lateral tilt, skin cleansing). Because the literature search for previous publication on this topic ended on Dec. 31, 2004, we searched from Jan. 1, 2005,
Results
From 5361 abstracts retrieved by our search, we identified 73 RCTs, 10 metaanalyses or systematic reviews, and 12 Cochrane reviews since Jan. 1, 2005. All technical aspects of CD with evidence-based recommendations and levels of certainty are summarized in Table 2. Additional techniques with RCTs since the review by Berghella et al4 include the following items: thromboprophylaxis, preoperative vaginal cleaning, indwelling bladder catheterization, Misgav-Ladach technique, supplemental oxygen,
Prophylactic antibiotics
Prophylactic antibiotic regimens comparing single-dose antibiotics with extended-spectrum coverage have been evaluated in 3 new RCTs.7, 8, 9 Specifically, randomized trials using ampicillin/sulbactam,7 triple antibiotic (ampicillin, gentamicin, and metronidazole),8 and penicillin and cephalothin9 did not demonstrate improved outcomes compared with standard cephalosporin prophylaxis. Thus, prophylaxis with a single dose of ampicillin or first-generation cephalosporins, such as cefazolin, should
Skin incision type
This has been evaluated in the context of general approaches to CD (Pfannenstiel, Joel-Cohen, Misgav-Ladach, modified Misgav-Ladach). These methods are summarized in Table 3 and incorporate multiple components, making assessment of each individual CD technique impossible. Four RCTs comparing Misgav-Ladach–based procedures with Pfannenstiel techniques noted improved operating times and possible cost savings in the former with minimal difference in maternal morbidity.31, 32, 33, 34 A Cochrane
Comment
Worldwide, cesarean delivery is the most frequent major operation performed. Therefore, it is imperative that surgeons who perform the operation use techniques that have been shown to minimize maternal morbidity and mortality. Fortunately, several aspects of the surgery are supported by evidence with a high level of certainty as defined by the USPSTF: previously, Berghella et al4 identified 5 such technical aspects, and the newer trials reviewed herein now support 10 such CD techniques (Table 4
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The authors report no conflict of interest.
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