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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

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Characteristics of included studies [ordered by study ID]
Berthet 1989

MethodsRandomisation to Mouchel incision or Pfannenstiel incision. Method of randomisation unclear.


Participants58 women undergoing caesarean section by Mouchel or Pfannenstiel incision. The study also included 61 women undergoing gynaecological surgery in Grenoble, France.


InterventionsMouchel (muscle-cutting) incision (n = 28) versus Pfannenstiel incision (n = 30).


OutcomesExtraction time.
Apgar scores.
Umbilical cord pH.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskInsufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskPotential risk of bias in assessment of extraction time and Apgar scores. intraoperative maternal variables studied. Cord pH estimated for all babies. Postoperative maternal assessment by single observer unaware of allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information.

Selective reporting (reporting bias)Unclear riskInsufficient information.

Other biasUnclear riskInsufficient information.

Franchi 2002

MethodsMulticentre study. Sealed envelopes containing computer-generated random codes.


ParticipantsWomen over 18 years, singleton pregnancy with indication for caesarean delivery in Varese, Italy and Berne, Switzerland. Exclusion criteria were: gestation less than 32 weeks, previous myomectomy, previous longitudinal abdominal incision, previous caesarean section prior to 32 weeks, 2 or more caesarean sections, maternal diseases requiring long-term medical treatment. 2 women in Joel-Cohen group were excluded after randomisation because they required caesarean hysterectomy.


InterventionsJoel-Cohen incision (n = 154) versus Pfannenstiel incision (n = 158) for laparotomic access.


OutcomesExtraction time defined as interval from skin incision to the clamping of the umbilical cord.
Total operative time defined as the time from skin incision to the end of the skin closure.
Postoperative morbidity defined when at least 1 of the following conditions occurred: wound infection grade 2-5, endometritis, sepsis, requirement of blood transfusion, febrile morbidity, puerperal infection, urinary tract infection, and requirement of a re-laparotomy.
Neurodevelopmental assessment of infant at 6 months of age by single neonatologist.


NotesAbdominal wound infection was graded with a 6-grade score. Febrile morbidity was defined as temperature elevation to 38 deg C on 2 occasions 4 h apart, excluding the first 24 h and in the absence of known operative or non-operative site infection. Puerperal endometritis was defined as postpartum temperature elevation to 38 deg C on 2 occasions 4 h apart with uterine tenderness, foul-smelling lochia, and no other apparent sources of fever.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomisation.

Allocation concealment (selection bias)Unclear riskEnvelopes used but unclear if sequentially numbered, opaque and sealed.

Blinding of participants and personnel (performance bias)
All outcomes
High riskSince surgical team was aware of allocated intervention, assessment of intraoperative variables (secondary outcomes) may have been subject to bias.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear if women and health workers providing postoperative newborn care and assessments were adequately blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low riskData from 1 woman in each group excluded after randomisation because of caesarean hysterectomy.

Selective reporting (reporting bias)Unclear riskInsufficient information.

Other biasUnclear riskInsufficient information.

Giacalone 2002

MethodsConsecutively-numbered, sealed envelopes containing allocation code.


ParticipantsWomen (n = 120) more than 18 years old and at gestation more than 37 weeks undergoing elective or emergency caesarean delivery in Montpelier, France. Excluded were women with scarred abdominal wall, previous caesarean delivery, hernia, multifetal gestation, grand multiparity, diabetes mellitus, myopathy, corticosteroid therapy during pregnancy, on anticoagulants or having haemostatic disorder, having general anaesthesia. Mother was not asked to participate when neonate was at risk of transfer to neonatal unit. Postoperative questionnaires and outcome variables were available for 97 (87%). Postoperative isokinetic assessment was performed on 54 of these women only.


InterventionsMaylard (muscle-cutting) incision (n = 43) versus Pfannenstiel incision (n = 54) for laparotomic access.


OutcomesIntraoperative and postoperative morbidity.
Immediate and late postoperative pain.
Health-related quality of life.
Evaluation of abdominal wall function by physical therapist.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table used.

Allocation concealment (selection bias)Low riskConsequently numbered, sealed envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
High riskSince surgical team was aware of allocated intervention, assessment of intraoperative variables may have been subject to bias.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskWomen and health workers providing postoperative care and assessment were unaware of allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskPostoperative questionnaires and outcome variables available for only 81% of women with fewer women in intervention arm.

Selective reporting (reporting bias)Unclear riskInsufficient information.

Other biasUnclear riskInsufficient information.

Mathai 2002

MethodsSealed, consecutively-numbered envelopes containing randomisation code. Block randomisation to 1 of 2 interventions.


ParticipantsWomen (n = 105) with singleton pregnancies at longitudinal lie at term requiring cesarean delivery under spinal anaesthesia in Vellore, India. Excluded were those with multiple pregnancy, any previous abdominal surgery, conditions where midline or paramedian incisions were planned, and where spinal anaesthesia was contraindicated. Spinal anaesthesia was ineffective in 1 in each group. 2 women in Joel Cohen group (1 underwent caesarean hysterectomy; 1 had vaginal delivery prior to caesarean section).


InterventionsJoel-Cohen incision (n = 51) versus Pfannenstiel incision (n = 50) for laparotomic access.


OutcomesAnalgesia on demand within the first 4 h after surgery.
Time between surgery and first dose of analgesic.
Time between skin incision and delivery of infant.
Time between skin incision and closure.
Estimated blood loss.
Time between surgery and intake of oral fluids.
Total dose of analgesics in first 24 h.
Febrile morbidity.
Haematocrit - preoperative and postoperative.
Time from surgery to start of breastfeeding.
Duration of stay in special care nursery.
Duration of postoperative hospitalisation.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBlock randomisation.

Allocation concealment (selection bias)Low riskSequentially numbered, opaque, sealed envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
High riskSince surgical team was aware of allocated intervention, assessment of intraoperative variables (secondary outcomes) may have been subject to bias.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskWomen and health workers providing postoperative care were not aware of allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low risk4 exclusions after randomisation - 1 in each group due to ineffective spinal analgesia; 1 in intervention group following caesarean hysterectomy for PPH; 1 in control group delivered vaginally before caesarean section.

Selective reporting (reporting bias)Unclear riskInsufficient information.

Other biasUnclear riskInsufficient information.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ansaloni 2001Alternate allocation, not randomised.

Ayers 1987Treatment allocation based on hospital number.

Ayres-de-Campos 2000Not enough data provided in abstract for assessment.

Behrens 1997Not enough data provided in abstract for assessment.

Bjorklund 2000Comparison of abdominal incisions along with different combinations of other steps of surgery.

Dani 1998Comparison of abdominal incisions along with different combinations of other steps of surgery.

Darj 1999Comparison of abdominal incisions along with different combinations of other steps of surgery.

Decavalas 1997Not enough data provided in abstract for assessment.

Direnzo 2001Not enough data provided in abstract for assessment.

Falls 1958Not a randomised controlled trial.

Ferrari 2001Comparison of abdominal incisions along with different combinations of other steps of surgery.

Franchi 1998Comparison of abdominal incisions along with different combinations of other steps of surgery.

Gaucherand 2001Treatment allocation by year of birth.

Hagen 1999Not enough data provided in abstract for assessment.

Heimann 2000Comparison of abdominal incisions along with different combinations of other steps of surgery.

HohlagschwandtnerNot a comparison of abdominal incisions.

Mahawerawat 2010Not a comparison of abdominal incisions.

Meyer 1997Not enough data provided in abstract for assessment.

Meyer 1998Not enough data provided in abstract for assessment.

Moreira 2002Comparison of abdominal incisions along with different combinations of other steps of surgery.

Oguz 1998Not a comparison of abdominal incisions

Redlich 2001Treatment allocation by first letter of surname.

Wallin 1999Comparison of abdominal incisions along with different combinations of other steps of surgery.

Xavier 1999Not enough data provided in abstract for assessment.

 
Characteristics of ongoing studies [ordered by study ID]
CORONIS 2007

Trial name or titleThe Coronis Trial.

MethodsInternational multicentre study of caesarean section surgical techniques: a randomised fractional, factorial trial.

ParticipantsWomen undergoing their first or second caesarean section through a transverse abdominal incision.

InterventionsFive comparisons using a 2 x 2 x 2 x 2 x 2 fractional factorial design:

  • Blunt versus sharp abdominal entry.
  • Exteriorisation of the uterus for repair versus intra-abdominal repair.
  • Single versus double layer closure of the uterus.
  • Closure versus non-closure of the peritoneum (pelvic and parietal).
  • Chromic catgut versus Polyglactin-910 for uterine repair.

OutcomesPrimary outcome: death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures; or blood transfusion.

Starting dateNot stated in reports.

Contact informationThe CORONIS Trial Collaborative Group, Peter Brocklehurst: peter.brocklehurst@npeu.ox.ac.uk

Notes

 
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]