M Mathai1, G J Hofmeyr. 1. World Health Organization, Department of Making Pregnancy Safer, Avenue Appia 20, Geneva, Switzerland, CH 1211. mathaim@who.int
Abstract
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.
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.
Authors: Blair J Wylie; Sharon Gilbert; Mark B Landon; Catherine Y Spong; Dwight J Rouse; Kenneth J Leveno; Michael W Varner; Steve N Caritis; Paul J Meis; Ronald J Wapner; Yoram Sorokin; Menachem Miodovnik; Mary J O'Sullivan; Baha M Sibai; Oded Langer Journal: Obstet Gynecol Date: 2010-06 Impact factor: 7.661