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Abdominal surgical incisions for caesarean section

  1. Matthews Mathai1,*,
  2. G Justus Hofmeyr2,
  3. Namratha E Mathai3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 31 MAY 2013

Assessed as up-to-date: 26 APR 2013

DOI: 10.1002/14651858.CD004453.pub3


How to Cite

Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD004453. DOI: 10.1002/14651858.CD004453.pub3.

Author Information

  1. 1

    World Health Organization, Department of Maternal; Newborn, Child & Adolescent Health, Geneva, Switzerland

  2. 2

    University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, Eastern Cape, South Africa

  3. 3

    Chambésy, Switzerland

*Matthews Mathai, Department of Maternal; Newborn, Child & Adolescent Health, World Health Organization, Avenue Appia 20, Geneva, CH 1211, Switzerland. mathaim@who.int.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 31 MAY 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Caesarean section is the commonest major operation performed on women worldwide. Operative techniques used for caesarean section vary and some of these techniques have been evaluated through randomised trials.

Various abdominal incisions have been used for caesarean delivery. These include vertical (midline and paramedian) incisions and transverse incisions (Pfannenstiel, Maylard, Cherney, Joel-Cohen). The type of incision used may depend on many factors including the clinical situation and the preferences of the operator.

Traditionally, vertical incisions were used for caesarean delivery (Myerscough 1982). Here the skin is incised in the midline between the umbilicus and the pubic symphysis. The rectus sheath and the peritoneum are incised in the midline. This area is the least vascular. Vertical subumbilical midline incisions have the presumed advantage of speed of abdominal entry and less bleeding. A vertical midline incision may be extended upwards if more space is required for access. Moreover, this incision may be used if a caesarean delivery is planned under local anaesthesia (WHO 2000). The disadvantages of a vertical midline incision include the greater risk of postoperative wound dehiscence and development of incisional hernia. The scar is cosmetically less pleasing. In the paramedian incision, the skin incision is made to one side of the midline (usually right). The anterior rectus sheath is opened under the skin incision. The belly of the underlying rectus abdominus muscle is then retracted laterally and the posterior rectus sheath and peritoneum are opened. Because of a shutter-like effect, the stress on the scar is presumed to be less. The paramedian incision is reportedly stronger (Kendall 1991) than the midline scar but has no cosmetic advantage.

The lower abdominal transverse incision is adequate for the vast majority of caesarean operations. It has the advantages of cosmetic approval and minimal risk of postoperative disruption. The risks of incisional hernia are less than those following vertical incisions. However, transverse abdominal incisions usually involve more dissection and may require more surgical skills. Blood loss following dissection may be more. Also, this incision may be difficult to make under local anaesthesia, though successful techniques have been described (Sreenivasan 2006). Transverse incisions are difficult to extend if increased access is required.

The traditional lower abdominal incision for caesarean delivery is the incision described in 1900 by Pfannenstiel. Classically, this incision is located two fingers-breadth above the pubic symphysis. Here the skin may be entered via a low transverse incision that curves gently upward, placed in a natural fold of skin (the 'smile' incision). After the skin is entered, the incision is rapidly carried through subcutaneous tissue to the fascia, which is then nicked on either side of the midline. The subcutaneous tissue is incised sharply with a scalpel. Once the fascia is exposed, it is incised transversely with heavy curved Mayo scissors. In the standard technique, the upper and then the lower fascial edges are next grasped with a heavy toothed clamp, such as a Kocher, and elevated. Under continuous tension, the fascia is then separated from the underlying muscles by blunt and sharp dissection. Once the upper and lower fascia have been dissected free, and any perforating vessel sutured or electrocoagulated, the underlying rectus abdominus muscles are separated with finger dissection. If the muscles are adherent, sharp dissection is necessary to separate them. The peritoneum is then opened sharply in the midline. The initial entry is then widened sharply with fine scissors exposing intraperitoneal contents.

When exposure is limited and additional space is required, the Maylard or Cherney modification may be used. In the Maylard procedure, the rectus abdominus muscles are divided either sharply or by electrocautery to allow greater access to the abdomen. However, this may result in a good deal of tissue damage and the underlying artery may be entered (O'Grady 1995). The Maylard incision length is usually longer than the Pfannenstiel incision. However, difficulty in delivery of the fetus is minimal with Pfannenstiel incisions measuring at least 15 cm in length (Ayers 1987), the length of a standard Allis clamp - the Allis clamp test (Finan 1991). Shorter incisions may lead to difficulty in general exposure or delivery of the baby's head, or both.

In the Cherney procedure, the lower fascia is reflected exposing the tendinous attachment of the rectus abdominus muscle bodies to the fascia of the pubis (O'Grady 1995). The muscle is severed as low as possible and the proximal and distal ends suture ligated. One or both muscle attachments may be divided as required.

The Mouchel incision is similar to the Maylard incision. This transverse incision runs at the upper limit of the pubic hair and is thus lower than the Maylard incision. The muscles are divided above the openings of the inguinal canals (Mouchel 1981).

In the Pelosi technique (Wood 1999) for caesarean delivery, the skin is cut in a low transverse fashion with a knife. The subcutaneous tissues and fascia are incised with electrocautery. The upper aspect of the fascial incision is elevated and the median raphe (line or ridge) is dissected cephalad (towards the head) 2 cm to 3 cm using electrocautery. The rectus muscles are separated bluntly with fingers to identify the underlying peritoneum, which is then entered by inserting the index finger inwards and upwards or sharply as required. The peritoneum and muscles are stretched to the full extent of the skin. In this technique, no bladder flap is created before incision of the uterus (hysterotomy). After delivery of the baby, the obstetrician awaits spontaneous placental expulsion before closing the hysterotomy in one layer. The fascia is closed and the skin edges are approximated with staples. The Pelosi technique was reported to be associated with decreased operative time, decreased blood loss, improved patient outcome and decreased overall cost (Wood 1999).

Joel-Cohen (Joel-Cohen 1977) described a transverse skin incision, which was subsequently adapted for caesarean sections. This modified incision is placed about 3 cm below the line joining the anterior superior iliac spines. This incision is higher than the traditional Pfannenstiel incision. Sharp dissection is minimised. After the skin is cut, the subcutaneous tissue and the anterior rectus sheath are opened a few centimetres only in the midline. The rectus sheath incision may be extended laterally by blunt finger dissection (Wallin 1999) or by pushing laterally with slightly opened scissor tips, deep to the subcutaneous tissues (Holmgren 1999). The rectus muscles are separated by finger traction. If exceptional speed is required in the transverse entry, the fascia may be incised in the midline and both the fascia and subcutaneous tissue are rapidly divided by blunt finger dissection (Joel-Cohen 1977). Stark used this incision for caesarean delivery along with single layer closure of the exteriorised uterus and non-closure of the peritoneum. This package of surgical techniques for caesarean section used at the Misgav-Ladach hospital, Jerusalem, has been popularised by Stark and others (Holmgren 1999). The reported advantages include shorter operating time (Darj 1999; Franchi 1998; Mathai 2002; Wallin 1999), less use of suture material (Bjorklund 2000), less intraoperative blood loss (Bjorklund 2000; Darj 1999; Wallin 1999), less postoperative pain (Darj 1999; Mathai 2002) and less wound infection (Franchi 1998) in the group undergoing caesarean by these techniques.

There are other Cochrane reviews on surgical techniques used at caesarean section, for example, techniques of repair of the uterine incision (Jokhan-Jacob 2004), techniques for closure of the abdominal wall (Anderson 2004) and skin (Alderdice 2003) after caesarean section. This review focuses specifically on abdominal surgical incisions for caesarean section.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

To determine, from the best available evidence, the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All comparisons of intention to perform caesarean section using different abdominal incisions. Quasi-randomised and cross-over trials were not included.

 

Types of participants

Pregnant women due for delivery by caesarean section.

 

Types of interventions

Abdominal incisions for caesarean section performed according to a prespecified technique.

 

Types of outcome measures

 

Primary outcomes

  1. Postoperative febrile morbidity as defined by trial authors;
  2. postoperative analgesia as defined by trial authors;
  3. blood loss as defined by the trial authors;
  4. blood transfusion.

 

Secondary outcomes

 
For the mother

  1. Duration of surgery;
  2. operative complications;
  3. postoperative complications;
  4. postoperative haemoglobin level;
  5. postoperative anaemia, as defined by trial authors;
  6. postoperative pyrexia;
  7. postoperative infection requiring additional antibiotic therapy;
  8. wound complications (haematoma, infection, breakdown);
  9. time to mobilisation;
  10. time to oral intake;
  11. time to return of bowel function;
  12. time to breastfeeding initiation;
  13. voiding problems;
  14. length of postoperative hospital stay;
  15. unsuccessful breastfeeding, as defined by trial authors;
  16. mother not satisfied;
  17. appearance of scar.

 
For the baby

  1. Time from anaesthesia to delivery;
  2. Apgar score;
  3. cord blood pH less than 7.20;
  4. birth trauma;
  5. admission to special care baby unit;
  6. encephalopathy.

 
Other

  1. Caregiver not satisfied;
  2. cost.

Outcomes were included if these were clinically meaningful; reasonable measures had been taken to minimise observer bias; missing data were insufficient to materially influence conclusions; data were available for analysis according to original allocation, irrespective of protocol violations; data were available in a format suitable for analysis.

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co-ordinator (28 February 2013).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of EMBASE;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords. 

We did not apply any language restrictions.

 

Data collection and analysis

For methods used to assess trials included in previous versions of this review, see Appendix 1.

The following methods were used to assess CORONIS 2007 (ongoing); Mahawerawat 2010; Oguz 1998 (excluded) and will be used in future revisions of the review.

 

Selection of studies

Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We resolved any disagreement through discussion or, if required, consulted the third author.

 

Data extraction and management

For this update of the review we did not identify any additional trials for inclusion. For future updates of this review, we will design a form to extract data. For eligible studies, at least two review authors will extract the data using the agreed form. We will resolve discrepancies through discussion or, if required, we will consult the third author. We will enter data into Review Manager software (RevMan 2011) and check for accuracy.

When information regarding any of the above is unclear, we will attempt to contact authors of the original reports to provide further details.

 

Assessment of risk of bias in included studies

For this version of the review, two review authors independently assessed the risk of bias for each previously included study using the revised criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third author.

 

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);
  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
  • unclear risk of bias.   

 

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear risk of bias.   

 

(3.1) Blinding of participants and personnel (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;
  • low, high or unclear risk of bias for personnel;

 

(3.2) Blinding of outcome assessment (checking for possible detection bias)

We described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received.  We assessed blinding separately for different outcomes or classes of outcomes.

We assessed methods used to blind outcome assessment as:

  • low, high or unclear risk of bias.

 

(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information was reported, or could be supplied by the trial authors, we re-included the missing data in the analyses which we undertook.

We assessed methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);
  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);
  • unclear risk of bias.

 

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it was clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review had been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes had been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest were reported incompletely and so could not be used; study fails to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.

 

(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We described for each included study any important concerns we had about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;
  • high risk of other bias;
  • unclear whether there was risk of other bias.

 

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Cochrane Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings. We planned to explore the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.

 

Measures of treatment effect

 

Dichotomous data

For dichotomous data, we presented results as summary risk ratio with 95% confidence intervals. 

 

Continuous data

For continuous data, we used the mean difference as outcomes were measured in the same way between trials. If in future updates we identify trials that measure the same outcome, but use different methods, we will use the standardised mean difference to combine trials.  

 

Unit of analysis issues

 

Cluster-randomised trials

If identified, we will include cluster-randomised trials in the analyses along with individually-randomised trials. We will adjust their sample sizes using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

We will also acknowledge heterogeneity in the randomisation unit and perform a sensitivity analysis to investigate the effects of the randomisation unit.

 

Cross-over trials

This study design is not eligible for inclusion in this review.

 

Dealing with missing data

For included studies, we noted levels of attrition. We planned to explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, we carried out analyses, as far as possible, on an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes were known to be missing.

 

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta-analysis using the T2, I² and Chi² statistics. We regarded heterogeneity as substantial if an I2 was greater than 30% and either the T2 was greater than zero, or there was a low P value (less than 0.10) in the Chi² test for heterogeneity. 

 

Assessment of reporting biases

In future updates of this review if there are 10 or more studies in the meta-analysis, we will investigate reporting biases (such as publication bias) using funnel plots. We will assess funnel plot asymmetry visually. If asymmetry is suggested by a visual assessment, we will perform exploratory analyses to investigate it.

 

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan 2011). We used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e. where trials were examining the same intervention, and the trials’ populations and methods were judged sufficiently similar. If in future updates of this review, there is clinical heterogeneity sufficient to expect that the underlying treatment effects differ between trials, or if substantial statistical heterogeneity is detected, we will use random-effects meta-analysis to produce an overall summary if an average treatment effect across trials is considered clinically meaningful. The random-effects summary will be treated as the average range of possible treatment effects and we will discuss the clinical implications of treatment effects differing between trials. If the average treatment effect is not clinically meaningful, we will not combine trials.

If we use random-effects analyses, the results will be presented as the average treatment effect with 95% confidence intervals, and the estimates of  T2 and I2.

 

Subgroup analysis and investigation of heterogeneity

We did not carry out any subgroup analyses. If we identify substantial heterogeneity in future versions of this review, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether an overall summary is meaningful, and if it is, use random-effects analysis to produce it.

We plan to carry out the following subgroup analyses:

  1. primary, repeat and mixed or undefined caesarean sections;
  2. general, regional and mixed or undefined anaesthesia;
  3. elective, emergency and mixed or undefined caesarean sections.

The following outcomes will be used in subgroup analyses:

  1. postoperative febrile morbidity as defined by trial authors;
  2. postoperative analgesia as defined by trial authors;
  3. blood loss as defined by the trial authors;
  4. blood transfusion.

We will assess subgroup differences by interaction tests available within RevMan (RevMan 2011). We will report the results of subgroup analyses quoting the χ2 statistic and P value, and the interaction test I² value.

 

Sensitivity analysis

In the event of significant heterogeneity, we will perform sensitivity analysis excluding trials with greater risk of bias to determine the effect on the results. Studies with high or unclear risk of bias for selection and/or attrition bias will be considered at high risk of bias and excluded in sensitivity analyses.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Description of studies

 

Results of the search

Twenty-nine reports were identified based on the search strategies. Four trials were included (Berthet 1989; Franchi 2002; Giacalone 2002; Mathai 2002) and 24 excluded (Ansaloni 2001; Ayers 1987; Ayres-de-Campos 2000; Behrens 1997; Bjorklund 2000; Dani 1998; Darj 1999; Decavalas 1997; Direnzo 2001; Falls 1958; Ferrari 2001; Franchi 1998; Gaucherand 2001; Hagen 1999; Heimann 2000; Hohlagschwandtner; Mahawerawat 2010; Meyer 1997; Meyer 1998; Moreira 2002; Oguz 1998; Redlich 2001; Wallin 1999; Xavier 1999). One study is a trial protocol of an ongoing study (CORONIS 2007).

 

Included studies

Only two studies (Franchi 2002; Mathai 2002) compared Joel-Cohen incision with Pfannenstiel incision for laparotomic access. Two studies compared transverse muscle-cutting incisions - Mouchel (Berthet 1989) and Maylard (Giacalone 2002) - with the Pfannenstiel incision and were included in the review. Thus a total of four studies involving 666 women comparing only different abdominal incisions for caesarean delivery were included in the review. Details of these studies are available in the Characteristics of included studies table.

 

Excluded studies

Four trials were excluded from the analyses as allocation to intervention groups were not based on randomisation in these trials (Ansaloni 2001; Ayers 1987; Gaucherand 2001; Redlich 2001). Two reports identified in the updated search were also excluded: Mahawerawat 2010 and Oguz 1998 did not compare different abdominal incisions.

Twelve studies compared various abdominal incisions either alone or in combinations with other steps carried out during caesarean delivery. Six studies( Dani 1998; Darj 1999; Ferrari 2001; Franchi 1998; Heimann 2000; Wallin 1999), which compared Joel-Cohen incision as part of the Misgav-Ladach technique with Pfannenstiel incision had differences in other steps between the two arms, such as closure of the uterotomy and peritoneum. These six studies were therefore excluded from the review, as were two studies (Bjorklund 2000; Moreira 2002) that compared the Misgav-Ladach technique with the vertical incision.

For details of all excluded studies, see the Characteristics of excluded studies table.

 

Risk of bias in included studies

The methodological quality of the included studies was variable.

See Figure 1 and Figure 2 for a summary of 'Risk of bias' assessments for included studies.

 FigureFigure 1. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 2. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

Method of randomisation was unclear in one trial (Berthet 1989) and allocation concealment unclear in two studies (Berthet 1989; Franchi 2002). Other studies were at low risk of selection bias.

 

Blinding

Given the type of intervention, the surgical team was aware of the allocated intervention. Assessment of some intraoperative variables, for example, time taken for surgery and estimated blood loss, may have been subject to bias. However, outcomes assessed in the immediate postoperative period, for example, febrile morbidity, pain, analgesic requirements, were less subject to bias.

 

Incomplete outcome data

Data were available for only 81% of women randomised in one trial (Giacalone 2002). The few post-randomisation exclusions in the other studies were for acceptable clinical reasons.

 

Selective reporting

There was insufficient information to assess selective reporting.

 

Other potential sources of bias

There was insufficient information to assess other potential sources of bias.

 

Effects of interventions

 

(1) Joel-Cohen incision versus Pfannenstiel incision

Two studies (Franchi 2002; Mathai 2002) compared the Joel-Cohen incision with Pfannenstiel incision. All other aspects of surgery in these two trials were similar in the two arms. Both trials (411 women) assessed postoperative febrile morbidity. 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) in the Joel-Cohen group,  Analysis 1.1. There was no significant heterogeneity among the trials.

Other outcomes were reported only in Mathai 2002 (101 women). Postoperative analgesic requirements were less in the Joel-Cohen group (RR 0.55, 95% CI 0.40 to 0.76),  Analysis 1.2; operating time was reduced (mean difference (MD) -11.40, 95% CI -16.55 to -6.25 minutes),  Analysis 1.17; delivery time was reduced (MD -1.90, 95% CI -2.53 to -1.27 minutes),  Analysis 1.21; the time to the first dose of analgesia was increased (MD 0.80, 95% CI 0.12 to 1.48 hours),  Analysis 1.3; the total dose of analgesia in the first 24 hours was reduced (MD -0.89, 95% CI -1.19 to -0.59),  Analysis 1.4; estimated blood loss was reduced (MD -58.00, 95% CI -108.51 to - 7.49 mL),  Analysis 1.8; and postoperative hospital stay for the mother was reduced (MD -1.50; 95% CI -2.16 to -0.84 days),  Analysis 1.25, compared with the Pfannenstiel group. All women in this study had had surgery under spinal analgesia. No other significant differences were found in either trial.

Women having Joel-Cohen incisions initiated breastfeeding earlier than those having Pfannenstiel incisions but this difference was not statistically significant (MD -5.50, 95% CI -13.62 to 2.62 hours),  Analysis 1.16. None of the studies reported on postoperative voiding difficulties. There was no difference in the duration of infant's stay in special care baby unit in the one study (101 participants) (Mathai 2002) that reported on this outcome (MD -0.46; 95% CI -0.95 to 0.03 days),  Analysis 1.26.

 

(2) Joel-Cohen incision versus vertical incision

No studies directly compared these incisions.

 

(3) Muscle cutting incision versus Pfannenstiel incision

Two studies compared muscle cutting incisions with Pfannenstiel incision. None of the outcomes of interest for this review were reported by Berthet 1989 comparing Mouchel incision with Pfannenstiel incision. Giacalone 2002 (97 women) compared Maylard incision with Pfannenstiel incision and reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50),  Analysis 2.1, need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98),  Analysis 2.2, or wound infection (RR 1.26, 95% CI 0.27 to 5.91),  Analysis 2.3, between the two groups. There was no difference in physical tests on muscle strength (Janda's test, Kumar 1995) three months postoperatively between the two incisions (54 women; MD 0.10, 95% CI -0.73 to 0.93),  Analysis 2.4. No difference was observed in postoperative hospital stay between Maylard muscle-cutting incision and Pfannenstiel incision (MD 0.40 days, 95% CI -0.34 to 1.14),  Analysis 2.5.

None of the studies reported on the need for readmission to the hospital for mother or baby. Maternal death, severe disability and thromboembolism were not reported by any of the included trials. There were no reports comparing other long-term wound problems such as incisional hernia, hypertrophic scar, future fertility problems, complications in later pregnancies and complications at later surgery. No subgroup analysis was done.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

The limited data comparing muscle-cutting incisions with Pfannenstiel incisions showed no differences.

The Joel-Cohen incision was associated with some immediate benefits for women undergoing caesarean delivery in comparison to the Pfannenstiel incision. Postoperative morbidity was less following this incision as indicated by fever, postoperative pain and analgesic requirements. Although measurements were subjective, estimated intraoperative blood loss was reportedly less with Joel-Cohen incision compared with Pfannenstiel and vertical incisions. The clinical significance of the reported difference (less than 100 mL) in estimated blood loss is probably less important in non-anaemic women but may be of greater significance in women with anaemia.

Caesarean delivery using the Joel-Cohen incision took less time than caesarean delivery by Pfannenstiel incision. The time from skin incision to delivery of the baby and the total duration of surgery were both shorter. However, it is unclear if the difference in time for delivery is of clinical significance. However, less time taken for surgery may be significant in situations where there is a shortage of operation theatre facilities and staff availability. Lastly, women having Joel-Cohen incision had shorter periods of hospitalisation compared with those undergoing the Pfannenstiel incision.

None of the studies reported on significant long-term outcomes such as long-term problems associated with surgery and outcomes in subsequent pregnancy.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

 

Implications for practice

The Joel-Cohen incision has several advantages compared with the Pfannenstiel incision. These include less fever, less pain (and therefore less analgesic requirements), less blood loss, shorter duration of surgery and shorter hospital stay. These advantages for the mother could be extrapolated to advantages for the health system through less demand on resources.

 
Implications for research

Opinions of women and caregivers were not evaluated. None of the studies have assessed severe immediate morbidity or long-term morbidity and mortality among mothers and infants. Larger trials, which include these outcomes and plan adequate follow-up at least until the end of the next pregnancy, would be required to assess these issues. Additional outcomes could include long-term pain, presence of numb patches, appearance of and satisfaction with scar, development of hernia, etc. There is a also need to study if these procedures can be carried out safely under local anaesthesia in settings where safe general or regional anaesthesia are not available.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

As part of the pre-publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team), one or more members of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group.  The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
Download statistical data

 
Comparison 1. Joel-Cohen versus Pfannenstiel incision

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Postoperative febrile morbidity2411Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.14, 0.87]

    1.1 Joel-Cohen versus Pfannenstiel incision
2411Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.14, 0.87]

 2 Postoperative analgesia on demand1101Risk Ratio (M-H, Fixed, 95% CI)0.55 [0.40, 0.76]

 3 Time between surgery and first dose of analgesic (hours)1101Mean Difference (IV, Fixed, 95% CI)0.80 [0.12, 1.48]

 4 Total dose of analgesics in 24 hours1101Mean Difference (IV, Fixed, 95% CI)-0.89 [-1.19, -0.59]

5 Number of analgesic injections required00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

6 Duration of analgesics (hours)00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

7 Number of analgesic doses required00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Estimated blood loss (mL)1101Mean Difference (IV, Fixed, 95% CI)-58.0 [-108.51, -7.49]

9 Change in pre- and postoperative haemoglobin levels (g)00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 10 Blood transfusion1310Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Wound infection as defined by trial authors1310Risk Ratio (M-H, Random, 95% CI)1.56 [0.45, 5.42]

12 Wound haematoma00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

13 Postoperative pain absent on day 100Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

14 Postoperative pain absent on day 200Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

15 "Significant" postoperative pain by visual analogue score00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 16 Time (hours) from surgery to start of breastfeeding1101Mean Difference (IV, Fixed, 95% CI)-5.5 [-13.62, 2.62]

 17 Total operative time (minutes)1101Mean Difference (IV, Fixed, 95% CI)-11.40 [-16.55, -6.25]

 18 Need for re-laparotomy1310Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

19 Long-term "significant" wound pain assessed by visual analogue score00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

20 Not satisfied with wound00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 21 Delivery time (minutes)1101Mean Difference (IV, Fixed, 95% CI)-1.90 [-2.53, -1.27]

22 5-minute Apgar score less than 700Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 23 Admissions to special care baby unit - all types1310Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.44, 3.20]

 24 Admission to special care baby unit - emergency caesarean section198Risk Ratio (M-H, Fixed, 95% CI)1.45 [0.54, 3.86]

 25 Postoperative hospital stay for mother (days)1101Mean Difference (IV, Fixed, 95% CI)-1.5 [-2.16, -0.84]

 26 Stay in special care nursery (days)1101Mean Difference (IV, Fixed, 95% CI)-0.46 [-0.95, 0.03]

 
Comparison 2. Muscle-cutting/Maylard versus Pfannenstiel incision

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Postoperative febrile morbidity197Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.08, 19.50]

 2 Blood transfusion197Risk Ratio (M-H, Fixed, 95% CI)0.42 [0.02, 9.98]

 3 Wound infection as defined by trial authors197Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.27, 5.91]

 4 Long-term complication - physical test at 3 months (Janda's test)154Mean Difference (IV, Fixed, 95% CI)0.10 [-0.73, 0.93]

 5 Postoperative hospital stay for mother (days)197Mean Difference (IV, Fixed, 95% CI)0.40 [-0.34, 1.14]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Appendix 1. Methods used to assess trials included in previous versions of this review

The following methods were used to assess Berthet 1989; Franchi 2002; Giacalone 2002; Mathai 2002.

 

Selection of studies

Both authors assessed for inclusion all potential studies we identified as a result of the search strategy.

 

Assessment of methodological quality of included studies

Both authors assessed the validity of each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005). Methods used for generation of the randomisation sequence are described for each trial.

 

(1) Selection bias (allocation concealment)

We assigned a quality score for each trial, using the following criteria:
(A) adequate concealment of allocation: such as telephone randomisation, consecutively-numbered, sealed opaque envelopes;
(B) unclear whether adequate concealment of allocation: such as list or table used, sealed envelopes, or study does not report any concealment approach;
(C) inadequate concealment of allocation: such as open list of random-number tables, use of case record numbers, dates of birth or days of the week.

 

(2) Attrition bias (loss of participants, for example, withdrawals, dropouts, protocol deviations)

We assessed completeness to follow-up using the following criteria:
(A) less than 5% loss of participants;
(B) 5% to 9.9% loss of participants;
(C) 10% to 19.9% loss of participants;
(D) more than 20% loss of participants.

 

(3) Performance bias (blinding of participants, researchers and outcome assessment)

We assessed blinding using the following criteria:

(A) blinding of participants (yes/no/unclear);

(B) blinding of caregiver (yes/no/unclear);

(C) blinding of outcome assessment (yes/no/unclear).

 

Data extraction and management

Both review authors extracted the data using the agreed form. Discrepancies were resolved through discussion. When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

 

Measures of treatment effect

Statistical analysis was carried out using the Review Manager software (RevMan 2003). We used fixed-effect meta-analysis for combining data in the absence of significant heterogeneity if trials were sufficiently similar.

 

Dichotomous data

For dichotomous data, we presented results as summary relative risk with 95% confidence intervals.

 

Continuous data

For continuous data, we used the weighted mean difference if outcomes were measured in the same way between trials.

 

Assessment of heterogeneity

We applied tests of heterogeneity between trials, if appropriate, using the I² statistic.

 

Subgroup analyses

We planned the following subgroup analyses:

  1. primary, repeat and mixed or undefined caesarean sections;
  2. general, regional and mixed or undefined anaesthesia.

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Last assessed as up-to-date: 26 April 2013.


DateEventDescription

26 April 2013New citation required but conclusions have not changedReview updated. Three trials were identified from the updated search, two were excluded (Mahawerawat 2010; Oguz 1998) and one is a report of an ongoing study (CORONIS 2007).

28 February 2012New search has been performedSearch updated.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Protocol first published: Issue 4, 2003
Review first published: Issue 1, 2007


DateEventDescription

28 August 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

M Mathai produced the first draft of the protocol and performed the first data extraction and analysis of the final review. GJ Hofmeyr revised the drafts, independently assessed trials for inclusion, and checked the data extraction. M Mathai and NE Mathai worked on the updated review and GJ Hofmeyr revised the updated draft and independently assessed the new data for inclusion.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Matthews Mathai is the author of one of the included trials.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Berthet 1989 {published and unpublished data}
  • Berthet J, Peresse JF, Rosier P, Racinet C. Comparative study of Pfannenstiel's incision and transverse abdominal incision in gynecologic and obstetric surgery [Etude comparative de l'incision de Pfannenstiel et de i'incision transversale transmusculaire en chirurgie gynecologique et obstetricale]. Presse Medicale 1989;18(29):1431-3.
Franchi 2002 {published data only (unpublished sought but not used)}
  • Franchi M, Ghezzi F, Raio L, Di Naro E, Miglierina M, Agosti M, et al. Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?. Acta Obstetricia et Gynecologica Scandinavica 2002;81:1040-6.
  • Ghezzi F, Franchi F, Raio L, Di Naro E, Balestreri D, Miglierina M, et al. Pfanenstiel or Joel-Cohen incision at cesarean delivery: a randomized clinical trial. American Journal of Obstetrics and Gynecology 2001;184(1):S166.
Giacalone 2002 {published data only (unpublished sought but not used)}
  • Giacalone PL, Daures JP, Vignal J, Herisson C, Hedon B, Laffargue F. Pfannenstiel versus Maylard incision for cesarean delivery: a randomized controlled trial. Obstetrics and Gynecology 2002;99:745-50.
Mathai 2002 {published data only}

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Ansaloni 2001 {published data only}
  • Ansaloni L, Brundisini R, Morino G, Kiura A. Prospective, randomized, comparative study of Misgav-Ladach versus traditional cesarean section at Nazareth Hospital, Kenya. World Journal of Surgery 2001;25(9):1164-72.
Ayers 1987 {published data only}
Ayres-de-Campos 2000 {published data only}
  • Ayres-de-Campos D, Patricio B. Modifications to the misgav ladach technique for cesarean section [letter]. Acta Obstetricia et Gynecologica Scandinavica 2000;79:326-7.
    Direct Link:
Behrens 1997 {published data only}
  • Behrens D, Zimmerman S, Stoz F, Holzgreve W. Conventional versus cohen-stark: a randomised comparison of the two techniques for cesarean section. 20th Congress of the Swiss Society of Gynecology and Obstetrics; 1997 June; Lugano, Switzerland. 1997:14.
Bjorklund 2000 {published and unpublished data}
Dani 1998 {published and unpublished data}
  • Dani C, Reali MF, Oliveto R, Temporin GF, Bertini G, Rubaltelli FF. Short-term outcome of newborn infants born by a modified procedure of cesarean section. Acta Obstetricia et Gynecologica Scandinavica 1998;77:929-31.
Darj 1999 {published and unpublished data}
  • Darj E, Nordstrom ML. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. Acta Obstetricia et Gynecologica Scandinavica 1999;78:37-41.
Decavalas 1997 {published data only}
  • Decavalas G, Papadopoulos V, Tzingounis V. A prospective comparison of surgical procedures in cesarean section. Acta Obstetricia et Gynecologica Scandinavica 1997;76(167):13.
Direnzo 2001 {published data only}
  • Direnzo GC, Rosati A, Cutuli A, Gerli S, Burnelli L, Liotta L, et al. A prospective trial of two procedures for performing cesarean section [abstract]. American Journal of Obstetrics and Gynecology 2001;185(1):S124.
Falls 1958 {published data only}
  • Falls FH. Recent advances in obstetric and gynecologic surgery. Journal of the American Medical Association 1958;166:1409-12.
Ferrari 2001 {published data only}
  • Ferrari AG, Frigerio LG, Candotti G, Buscaglia M, Petrone M, Taglioretti A, et al. Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity?. International Journal of Gynecology & Obstetrics 2001;72:135-43.
Franchi 1998 {published data only (unpublished sought but not used)}
  • Franchi M, Ghezzi F, Balestreri D, Beretta P, Maymon E, Miglierina M, et al. A randomized clinical trial of two surgical techniques for cesarean section. American Journal of Perinatology 1998;15(10):589-94.
  • Franchi M, Ghezzi F, Balestreri D, Miglierina M, Zanaboni F, Donadello N, et al. A randomized clinical trial of two surgical techniques for cesarean section. American Journal of Obstetrics and Gynecology 1998;178:S31.
Gaucherand 2001 {published data only}
  • Gaucherand P, Bessai K, Sergeant P, Rudigoz RC. Towards simplified cesarean section? [Vers une simplification de l'operation cesarienne?]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2001;30:348-52.
Hagen 1999 {published data only}
  • Hagen A, Schmid O, Runkel S, Weitzel H, Hopp H. A randomized trial of two surgical techniques for cesarean section. European Journal Obstetrics, Gynecology and Reproductive Biology 1999;86:S81.
Heimann 2000 {published data only (unpublished sought but not used)}
  • Heimann J, Hitschold T, Muller K, Berle P. Randomized trial of the modified Misgav-Ladach and the conventional Pfannenstiel techniques for cesarean section [Modifizierte Misgav-Ladach-Technik der Sectio caesarea im Vergleich mit einer konventionellen Pfannenstiel-technik- eine prospektiv-randomisierte Studie an 240 Patientinnen eines Perinatalzentrums]. Geburtshilfe und Frauenheilkunde 2000;60:242-50.
Hohlagschwandtner {published data only}
  • Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesarean necessary?. A randomized trial. Obstetrics & Gynecology 2001;98:1089-92.
Mahawerawat 2010 {published data only}
  • Mahawerawat S. Comparison of unintended uterine extension between cephalad-caudad and transverse blunt expansion techniques for low transverse cesarean delivery. Thai Journal of Obstetrics and Gynaecology 2010;18:120-5.
Meyer 1997 {published data only}
  • Meyer BA, Narain H, Morgan M, Jaekle RK. Comparison of electrocautery vs knife for elective cesarean in non-labored patients. American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S121.
Meyer 1998 {published data only}
  • Meyer BA, Narain H, Morgan M, Jaekle RK. Comparison of electrocautery vs knife for elective cesarean in labored patients. American Journal of Obstetrics and Gynecology 1998;178(1 Pt 2):S80.
Moreira 2002 {published data only (unpublished sought but not used)}
  • Moreira P, Moreau JC, Faye ME, Ka S, Kane Gueye SM, Faye EO, et al. Classic and Misgav-Ladach cesarean: results of a comparative study [Comparaison de deux techniques de cesarienne: cesarienne classique versus cesarienne Misgav Ladach]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2002;31:572-6.
Oguz 1998 {published data only}
  • Oguz S, Sener B, Ozcan S, Akyol D, Gokmen O. Nonfreeing of the lower leaf of the rectus sheath at caesarean section: a randomized controlled trial. Australian and New Zealand Journal of Obstetrics and Gynaecology 1998;38(3):317-8.
Redlich 2001 {published data only}
  • Redlich A, Koppe I. The "gentle caesarean section" - an alternative to the classical way of section. A prospective comparison between the classical technique and the method of Misgav Ladach ["Die sanfte Sectio" - Eine Alternative zur klassischen Sectiotechnik. Prospektiver Vergleich der klassischen Technik mit der Misgav-Ladach-Methode]. Zentralblatt fur Gynakologie 2001;123:638-43.
Wallin 1999 {published and unpublished data}
  • Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery. British Journal of Obstetrics and Gynaecology 1999;106:221-6.
  • Wallin G, Fall O. Modified Joel-Cohen technique for caesarean section. A prospective randomised trial. Acta Obstetricia et Gynecologica Scandinavica 1997;76(167 Suppl):24.
Xavier 1999 {published data only}
  • Xavier P, Ayres-de-Campos D, Reynolds A, Guimaraes M, Santos C, Patricio B. A randomised trial of the misgav-ladach versus the classical technique for the caesarean section: preliminary results [abstract]. European Journal Obstetrics, Gynecology and Reproductive Biology 1999;86:S28-S29.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
CORONIS 2007 {published data only}
  • Juszczak E, Farrell B. The CORONIS Trial: international study of caesarean section surgical techniques. Trials 2011;112(Suppl 1):A103.
  • The CORONIS Trial Collaborative Group. The CORONIS trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial. BMC Pregnancy and Childbirth 2007;7:24.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Alderdice 2003
  • Alderdice F, McKenna D, Dornan J. Techniques and materials for skin closure in caesarean section. Cochrane Database of Systematic Reviews 2003, Issue 2. [DOI: 10.1002/14651858.CD003577]
Anderson 2004
  • Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. [DOI: 10.1002/14651858.CD004663.pub2]
Finan 1991
  • Finan MA, Mastrogiannis DS, Spellacy WN. The Allis test for easy cesarean delivery. American Journal of Obstetrics and Gynecology 1991;164:772-5.
Higgins 2005
  • Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005}. In: The Cochrane Library, Issue 2, 2005. Chichester, UK: John Wiley & Sons, Ltd.
Higgins 2011
  • Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Holmgren 1999
  • Holmgren G, Sjoholm L, Stark M. The misgav ladach method for cesarean section: method description. Acta Obstetricia et Gynecologica Scandinavica 1999;78:615-21.
Joel-Cohen 1977
  • Joel-Cohen S. Abdominal and Vaginal Hysterectomy. 2nd Edition. Philadelphia: JB Lippincott, 1977:18-23.
Jokhan-Jacob 2004
  • Jacob-Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. [DOI: 10.1002/14651858.CD000085.pub2]
Kendall 1991
Kumar 1995
Mouchel 1981
Myerscough 1982
  • Myerscough PR. Caesarean section: sterilization: hysterectomy. Munro Kerr's Operative Obstetrics. 10th Edition. London: Bailliere Tindall, 1982:295-319.
O'Grady 1995
  • O'Grady JP, Veronikis DK, Chervenak FA, McCullough LB, Kanaan CM, Tilson JL. Cesarean delivery. In: O'Grady JP, Gimovsky ML editor(s). Operative Obstetrics. Baltimore: Williams & Wilkins, 1995:239-87.
RevMan 2003
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 4.2 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003.
RevMan 2011
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Sreenivasan 2006
  • Sreenivasan KA. [Caesarean under local anaesthesia: a study of 1543 cases]. Conference Proceedings: 49th All India Congress of Obstetrics & Gynaecology; 2006; Kochi, Kerala. 2006:168. [: IP-9-2-0200-2-OBST]
WHO 2000
  • WHO/UNFPA/UNICEF/World Bank. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. WHO/UNFPA/UNICEF/World Bank; 2000. Report No.:WHO/RHR/00.7.
Wood 1999

References to other published versions of this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Mathai 2006
  • Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. [DOI: 10.1002/14651858.CD004453]
Mathai 2007