Systematic reviews
Obstetrics
Evidence-based surgery for cesarean delivery: an updated systematic review

https://doi.org/10.1016/j.ajog.2013.02.043Get rights and content

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

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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