Tecnicas Cesarea

Tcnicas para la cesrea
Hofmeyr GJ, Mathai M, Shah A, Novikova N

Reproduccin de una revisin Cochrane, traducida y publicada en La Biblioteca Cochrane Plus, 2008, Nmero 2
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NDICE DE MATERIAS RESUMEN...................................................................................................................................................................1 RESUMEN EN TRMINOS SENCILLOS....................................................................................................................2 ANTECEDENTES........................................................................................................................................................2 OBJETIVOS.................................................................................................................................................................5 CRITERIOS PARA LA VALORACIN DE LOS ESTUDIOS DE ESTA REVISIN......................................................5 ESTRATEGIA DE BSQUEDA PARA LA IDENTIFICACIN DE LOS ESTUDIOS....................................................6 MTODOS DE LA REVISIN.....................................................................................................................................6 DESCRIPCIN DE LOS ESTUDIOS..........................................................................................................................7 CALIDAD METODOLGICA.......................................................................................................................................8 RESULTADOS.............................................................................................................................................................8 DISCUSIN.................................................................................................................................................................9 CONCLUSIONES DE LOS AUTORES......................................................................................................................10 AGRADECIMIENTOS................................................................................................................................................10 POTENCIAL CONFLICTO DE INTERS...................................................................................................................10 FUENTES DE FINANCIACIN..................................................................................................................................10 REFERENCIAS.........................................................................................................................................................11 TABLAS......................................................................................................................................................................16 Characteristics of included studies.....................................................................................................................16 Characteristics of excluded studies....................................................................................................................22 Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques.........................23 Table 02 Routine caesarean section technique based on the best available evidence......................................30 CARTULA................................................................................................................................................................32 RESUMEN DEL METANLISIS.................................................................................................................................33 GRFICOS Y OTRAS TABLAS..................................................................................................................................36 01 Joel-Cohen based versus Pfannenstiel (all trials)..........................................................................................36 01 Serious complications.............................................................................................................................36 02 Blood loss...............................................................................................................................................37 03 Blood transfusion....................................................................................................................................38 04 Operating time (minutes)........................................................................................................................39 07 Postoperative haematocrit level..............................................................................................................40 08 Haemoglobin fall > 4 g%.........................................................................................................................40 09 Wound infection......................................................................................................................................41 10 Wound haematoma.................................................................................................................................42 11 Wound breakdown..................................................................................................................................42 12 Endometritis............................................................................................................................................43 13 Time to mobilisation (hours)...................................................................................................................44 14 Time to oral intake (hours)......................................................................................................................45 15 Time to return of bowel function (hours).................................................................................................46 16 Time to breastfeeding initiation (hours)...................................................................................................46
Copyright John Wiley & Sons Ltd. Usado con permiso de John Wiley & Sons, Ltd.
NDICE DE MATERIAS
17 Fever treated with antibiotics or as defined by trial authors....................................................................47 18 Repeat operative procedures on the wound...........................................................................................48 19 Postoperative pain as measured by trial authors....................................................................................48 20 Number of analgesic injections...............................................................................................................49 24 Time from skin incision to delivery (minutes)..........................................................................................50 28 Apgar score < 7 at 5 minutes..................................................................................................................51 29 Neonatal intensive care admission.........................................................................................................51 37 Length of postoperative stay for mother (days).......................................................................................52 04 Joel-Cohen based versus traditional (lower midline incision) (all trials).........................................................52 02 Blood loss...............................................................................................................................................52 03 Blood transfusions..................................................................................................................................52 04 Operating time........................................................................................................................................53 08 Postoperative anaemia...........................................................................................................................53 09 Wound infection......................................................................................................................................53 11 Wound breakdown..................................................................................................................................54 12 Endometritis............................................................................................................................................54 13 Time to mobilistion..................................................................................................................................54 17 Fever treated with antibiotics or as defined by trialists...........................................................................55 37 Length of postoperative hospital stay for mother....................................................................................55 07 Misgav-Ladach versus modified Misgav-Ladach (all trials)...........................................................................55 02 Blood loss...............................................................................................................................................55 04 Operating time........................................................................................................................................56 14 Time to oral intake..................................................................................................................................56 15 Time to return of bowel function.............................................................................................................56 19 Postoperative pain as measured by trial authors....................................................................................57 24 Time from skin incision to delivery..........................................................................................................57 37 Length of postoperative hospital stay for mother....................................................................................57 10 Extraperitoneal versus intraperitoneal caesarean section.............................................................................58 01 Serious complications.............................................................................................................................58 05 Maternal mortality...................................................................................................................................58 17 Fever treated with antibiotics or as defined by trialists...........................................................................58 18 Repeat operative procedures on the wound...........................................................................................59
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Hofmeyr GJ, Mathai M, Shah A, Novikova N
Esta revisin debera citarse como: Hofmeyr GJ, Mathai M, Shah A, Novikova N. Tcnicas para la cesrea (Revisin Cochrane traducida). En: La Biblioteca Cochrane Plus, 2008 Nmero 2. Oxford: Update Software Ltd. Disponible en: http://www.update-software.com. (Traducida de The Cochrane Library, 2008 Issue 2. Chichester, UK: John Wiley & Sons, Ltd.). Fecha de la modicacin signicativa ms reciente: 06 de noviembre de 2007
RESUMEN Antecedentes Las tasas de cesrea se han incrementado a nivel mundial. Es importante utilizar la tcnica ms efectiva y segura. Objetivos Para comparar los efectos de los mtodos completos de la cesrea; y para resumir los resultados de las revisiones de los aspectos individuales de la tcnica de la cesrea. Estrategia de bsqueda Se realizaron bsquedas en el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) (agosto 2007), en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library 2007, nmero 3) y en las listas de referencias de los artculos identicados. Criterios de seleccin Ensayos controlados aleatorios donde la intencin es realizar la cesrea mediante diferentes tcnicas. Recopilacin y anlisis de datos Dos autores de la revisin de forma independiente evaluaron los estudios y extrajeron los datos. Resultados principales La cesrea de Joel-Cohen en comparacin con Pfannenstiel se asoci con: menor prdida sangunea, (cinco ensayos, 481 mujeres; diferencia de medias ponderada [DMP -64,45 ml; intervalo de conanza (IC) del 95%: 91,34 a -37,56 m); tiempo de operacin ms corto (cinco ensayos, 581 mujeres; DMP -18,65; IC del 95%: -24,84 a -12,45 minutos); despus de la ciruga, tiempo reducido para la ingesta oral (cinco ensayos, 481 mujeres; DMP -3,92; IC del 95%: -7,13 a -0,71 horas); menos ebre [ocho ensayos, 1 412 mujeres; riesgo relativo (RR) 0,47; IC del 95%: 0,28 a 0,81); duracin ms breve del dolor postoperatorio (dos comparaciones de un ensayo, 172 mujeres; DMP -14,18 horas; IC del 95%: -18,31 a -10,04 horas); menos inyecciones de frmacos analgsicos (dos ensayos, 151 mujeres; DMP -0,92; IC del 95%: -1,20 a -0,63); y tiempo ms corto desde la incisin cutnea al nacimiento del beb (cinco ensayos, 575 mujeres; DMP -3,84 minutos; IC del 95%: -5,41 a -2,27 minutos). Las complicaciones graves y las transfusiones de sangre eran muy pocos para un anlisis. Misgav-Ladach en comparacin con el mtodo tradicional (incisin abdominal de la lnea media baja) se asoci con menos: prdida sangunea (339 mujeres; DMP -93,00; IC del 95%: -132,72 a -53,28 ml); tiempo de operacin (339 mujeres; DMP -7,30; IC del 95%: -8,32 a -6,28 minutos); tiempo hasta la movilizacin (339 mujeres; DMP -16,06; IC del 95%: -18,22 a -13,90 horas); y duracin de la estancia hospitalaria potsoperatoria para la madre (339 mujeres; DMP -0,82; IC del 95%: -1,08 a -0,56 das). Misgav-Ladach en comparacin con los mtodos de Misgav-Ladach modicados se asoci con un tiempo mayor desde la incisin cutnea al nacimiento del beb (116 mujeres; DMP 2,10; IC del 95%: 1,10 a 3,10 minutos).
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Conclusiones de los autores Los mtodos de Joel-Cohen tienen ventajas en comparacin con las tcnicas de cesrea de Pfannenstiel y la tradicional (lnea media baja), lo que se puede traducir en ahorros para el sistema de salud. Sin embargo, estos ensayos no facilitan informacin sobre la mortalidad y sobre la morbilidad grave o a largo plazo como la morbilidad por adherencia de la placenta y la rotura de cicatrices.
RESUMEN EN TRMINOS SENCILLOS Tcnicas para la cesrea Las cesreas se realizan como procedimientos electivos o de urgencia y el nmero de intervenciones est en aumento. Las principales complicaciones son dao a los rganos, complicaciones con la anestesia, hemorragia, infeccin y tromboembolismo. Las tcnicas utilizadas varan considerablemente. Las pruebas disponibles de los ensayos controlados aleatorios sugiere que las tcnicas basadas en Joel-Cohen (Joel-Cohen, Misgav-Ladach) tienen ventajas a corto plazo por encima de los mtodos Pfannenstiel (11 ensayos) y la tradicional lnea media inferior (dos ensayos). Se reduce la prdida de sangre, el tiempo de operacin, el tiempo desde la incisin cutnea al nacimiento del beb, el uso de calmantes, el tiempo para la ingesta oral y la funcin intestinal o la movilizacin y la ebre. El uso de los mtodos basados en Joel-Cohen podra obtener resultados a corto plazo mejorados y ahorros para los sistemas de salud pero se necesitan datos slidos sobre las medidas de resultado a largo plazo (dolor, fertilidad, morbilidad por adherencia de la placenta y rotura del tero) despus de diferentes tcnicas (que incluyen capas de sutura dobles en comparacin con el cierre uterino de una sola capa).
ANTECEDENTES La cesrea es una de las principales operaciones abdominales realizadas con mayor frecuencia en mujeres tanto de pases prsperos como de bajos recursos. Las tasas varan considerablemente entre los pases y los servicios de salud (Dumont 2001; Murray 1997; Pai 1999). Las estimaciones globales indican una tasa de cesrea a nivel mundial del 15%, con una variacin del 3,5% en frica a un 29,2% en Latinoamrica y el Caribe (Betran 2007). Los estudios de Estados Unidos (Menacker 2001), el Reino Unido (Thomas 2001) y China (Cai 1998) reportan tasas entre un 20% y un 25%. Un estudio en Latinoamrica descubri una variacin del 1,6% en un hospital Haitiano al 40% en Chile, y por encima del 50% en la mayora de los hospitales privados (Belizan 1999). Las tasas de los pases africanos del oeste y el este variaron entre un 0,3% en Nger y un 10,5% en Kenia (Beukens 2001). Antes de 1970, las tasas de cesrea en la mayora de los pases con recursos medios y altos variaban entre un 3% y un 5%. Existen muchas formas posibles de realizar una cesrea. Un estudio de obstetras del Reino Unido descubri una amplia variacin en las tcnicas (Tully 2002). Para una ciruga electiva ms del 80% utiliz la apertura abdominal Pfannenstiel y un cierre uterino de doble capa. Para una ciruga de emergencia, la mayora utiliz la apertura abdominal Joel-Cohen. Una encuesta Norteamericana de residentes de obstetricia y ginecologa descubri que el 77% utiliz una incisin Pfannenstiel para una cesrea urgente o de emergencia; el 55% utiliz un cierre de una sola capa de la incisin uterina, el 37% utiliz un cierre de doble capa, mientras que el 11% utiliz un cierre de una sola capa nicamente en mujeres bajo una esterilizacin concomitante (Dandolu 2006). La historia de las tcnicas de cesrea ha sido revisada por Lurie 2003. Las tcnicas utilizadas dependen de varios factores, entre los que se incluyen la situacin clnica y las preferencias del cirujano. La cesrea a menudo se realiza como un procedimiento de emergencia despus de algunas horas cuando el personal superior no se encuentra disponible de inmediato. Es importante que todos los que realicen esta operacin utilicen las tcnicas ms efectivas y seguras, como lo determina la revisin sistemtica de los ensayos aleatorios. La cesrea puede ser un procedimiento electivo o de emergencia (usualmente durante el trabajo de parto). Las causas comunes para realizar una cesrea incluyen: 1. evolucin insuciente en el trabajo de parto; 2. presunto sufrimiento fetal (ver revisin "Tratamiento quirrgico versus conservador para el "sufrimiento fetal" en el trabajo de parto" (Hofmeyr 1998)); 3. ciruga uterina previa; 4. muy bajo peso al nacer (ver revisin "Cesrea electiva versus tratamiento expectante para el alumbramiento de un beb pequeo" (Grant 2001));
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5. mala presentacin del feto (p.ej.: presentacin transversa, podlica)(ver revisin "Cesrea programada para un parto podlico a trmino" (Hofmeyr 2003)); 6. placenta previa (ver revisin "Intervenciones para una presunta placenta previa" (Neilson 2003a)); 7. desprendimiento placentario (ver revisin "Intervenciones para el tratamiento del desprendimiento placentario" (Neilson 2003b)); 8. embarazo mltiple (ver revisin "Parto por cesrea para el segundo gemelar" (Crowther 1996)); 9. presunta desproporcin fetoplvica (ver revisin "Pelvimetra para presentaciones ceflicas fetales a trmino" (Pattinson 1997)); 10. prolapso del cordn; 11. preeclampsia grave, sndrome de HELLP o eclampsia; 12. infecciones maternas (p. ej., VIH, Herpes simple activo)(ver revisin "Intervenciones para reducir el riesgo de transmisin de la infeccin de VIH de madre a hijo" (Brocklehurst 2002)); 13. eleccin de la madre (ver "Cesrea por razones no mdicas a trmino" (Lavender 2006) (Bhague 2002; Efekhar 2000; Feldman 1985). Las indicaciones menos comunes incluyen defectos de coagulacin fetales (Silver 2000) y algunas anomalas fetales (How 2000; Luthy 1991). El foco de esta revisin se encuentra en las tcnicas quirrgicas para la cesrea pero, para que sea completa, se cubrirn brevemente algunos aspectos de la anestesia y del cuidado pre y postoperatorio. La preparacin preoperatoria incluye una evaluacin clnica; anlisis de sangre como la hemoglobina, el grupo Rhesus y un cribado de anticuerpos, pruebas de slis y VIH, y prueba de compatibilidad de la sangre en casos de alto riesgo (Cousins 1996; Ransom 1999); evaluacin de anestesia; restriccin de la ingesta oral cuando se anticipa la cesrea (ver revisin "Restriccin de los alimentos y uidos orales durante el trabajo de parto" (Singata 2002)); intervenciones para reducir el volumen o la acidez de los contenidos del estmago (Peskett 1973); lquidos intravenosos (prevencin de la dextrosa excesiva) (Kenepp 1982); prolaxis antibitica (ver revisiones "Prolaxis antibitica para la cesrea" (Smaill 2002), y "Regmenes y frmacos de prolaxis antibitica para la cesrea" (Hopkins 1999)); y prolaxis antirretroviral para mujeres con pruebas positivas para VIH que an no reciban tratamiento antirretroviral (ver revisin "Antirretrovirales para la reduccin del riesgo de transmisin maternoinfantil de la infeccin por VIH" (Volmink 2007)). Se coloca una sonda urinaria, y puede rasurarse el vello en la regin de la incisin cutnea propuesta. La cuestin de la prolaxis en contra de un tromboembolismo venoso es tratada en una revisin aparte ("Prolaxis para una enfermedad tromboemblica venosa en el embarazo y el perodo posnatal temprano" (Gates 2002)). En el quirfano, se verica la ubicacin, presentacin y posicin del feto, y se conrma la presencia de latidos fetales. Se revisa la indicacin para la cesrea, dado que la situacin obsttrica puede haberse
modicado a partir del momento en que se tom la decisin original. La preparacin incluye la capacidad de optar por cesreas de emergencia dentro de un tiempo limitado (p.ej.: 30 minutos) (ACOG 2001; James 2001), a pesar de que la viabilidad de este estndar ha sido cuestionada (MacKenzie 2001; Tufnell 2001). La analgesia regional (espinal y epidural) ha reemplazado ampliamente a la anestesia general en muchos servicios. Cuando otros mtodos no se encuentran disponibles o no son seguros, puede utilizarse la inltracin analgsica local (Hofmeyr 1995; Ranney 1975). Los aspectos de la eleccin y la tcnica anestsica son tratados en otras revisiones (ver el protocolo para la revisin "Anestesia espinal versus epidural para la cesrea" (Ng 2004); "Tcnicas para la prevencin de la hipotensin durante la anestesia espinal para la cesrea" (Cyna 2006)). El cuidado postoperatorio incluye un chequeo regular de los signos vitales y de la diuresis, y de los signos de relajacin uterina y hemorragia. No se ha descubierto ningn benecio en la restriccin de la ingesta oral ("Los alimentos y lquidos orales tempranos en comparacin con los tardos despus de una cesrea" (Mangesi 2002)). Se provee la analgesia ("Dosis oral nica de ibuprofeno y diclofenac para el dolor postoperatorio" (Collins 1999); "Dosis nica de oxicodona y oxicodona ms paracetamol (acetaminofeno) para el dolor postoperatorio agudo" (Edwards 2000); "Dosis nica de paracetamol (acetaminofeno), con y sin codena, para el dolor postoperatorio" (Moore 1998)). Se incentiva la movilidad temprana, el contacto piel a piel con el beb (Moore 2007) y la lactancia. Las principales complicaciones de la cesrea son el dao intraoperatorio a los rganos como la vejiga o los urteres (Nielsen 1984), complicaciones anestsicas, hemorragia (Petitti 1985), infeccin (Duff 1986; Owen 1994) y tromboembolismo (Gherman 1999; Simpson 2001). La mortalidad materna es mayor despus de una cesrea que en un parto vaginal (Frigoletto 1980; Lilford 1990; Schuitemaker 1997), a pesar de que es difcil de saber hasta qu punto esto se debe a la operacin o a la causa de la operacin. La taquipnea transitoria del recin nacido es ms comn despus de una cesrea, y no se descarta un parto traumtico (Nielsen 1984). Los riesgos a largo plazo incluyen un riesgo aumentado de placenta previa (Ananth 1997), desprendimiento placentario (Lydon-Rochelle 2001a), placenta acreta (Clarke 1985) y ruptura uterina (Lydon-Rochelle 2001b). A lo largo de los aos, se han desarrollado muchas variaciones en la tcnica de la cesrea. Algunos aspectos de la tcnica se tratan en revisiones separadas. 1. La posicin de la mujer puede ser supina o con una inclinacin lateral ("Inclinacin lateral para la cesrea" (Wilkinson 2006a)). 2. La incisin cutnea puede ser vertical (lnea media o paramediana) o abdominal inferior transversal (Pfannenstiel,
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Joel-Cohen, Pelosi, Mouchel o Cherney). Para las mujeres muy obesas, se sugiere una incisin transversal arriba del ombligo, pero no se ha demostrado que disminuya la morbilidad (Houston 2000). Se ha comparado la incisin con bistur elctrico y con bistur en fro para la apertura de la pared abdominal (Meyer 1998). La hoja inferior de la vaina subrrectal pude liberarse o no (Oguz 1998). Se encuentra disponible una revisin de Cochrane sobre las incisiones quirrgicas abdominales para la cesrea (Mathai 2007). 3. El peritoneo de la vejiga puede reejarse de forma descendente o no (Hohlagschwandtn 2001). 4. La incisin uterina puede ser el segmento inferior transversal (Munro-Kerr), el segmento inferior de lnea media o el segmento superior ("clsico"). 5. El tero puede abrirse con bistur, tijera, por medio de una diseccin sin corte, o con el uso de grapas absorbibles ("Grapas absorbibles para la incisin uterina durante la cesrea" (Wilkinson 2006b)). 6. La placenta puede retirarse manualmente o con traccin del cordn, y el permitir el sangrado del cordn se ha empleado para contribuir al desprendimiento placentario ("Extraccin manual de la placenta en la cesrea" (Wilkinson 2006c)). 7. El tero puede ser liberado desde la cavidad abdominal o dejarlo en posicin durante la reparacin ("Reparacin extraabdominal versus intraabdominal de la incisin uterina en la cesrea" (Jacobs-Jokhan 2004)). 8. El tero puede cerrase con suturas interrumpidas o continuas en una, dos o tres capas ("Mtodos de cierre de la incisin uterina en la cesrea"/"Sutura de una sola capa versus capa doble para el cierre de la incisin uterina en la cesrea" (Enkin 2006). Los estudios observacionales han sugerido que el cierre de una sola capa se asocia con mayores defectos de cicatriz de ecografa (Hayakawa 2006) y tiene una mayor tendencia a despegarse en embarazos posteriores (Bujold 2002; Gyam 2006; Hamilton 2001). En otro estudio, se descubrieron "ventanas" uterinas aumentadas despus de un cierre de una sola capa, pero no ocurrieron roturas de la cicatriz (Durnwald 2003). 9. La sangre puede recuperarse durante el procedimiento para una nueva transfusin (Rainaldi 1998). 10. El peritoneo visceral o el parietal, o ambos, pueden suturase o dejarse sin sutura ("Sin cierre del peritoneo en la cesrea" (Bamigboye 2003)). 11. Se pueden utilizar varios materiales para el cierre de la fascia. En mujeres con un riesgo aumentado de dehiscencia de la herida, se sugiere la realizacin de una sutura Smead-Jones (Wallace 1980). 12. Para reducir el riego de una infeccin se sugiere un cuidadoso manejo de los tejidos y una buena tcnica quirrgica (Iffy 1979; Lyon 1987). 13. Los tejidos subcutneos pueden suturarse o no (Naumann 1995). 14. Se pueden utilizar varias tcnicas y materiales para el cierre cutneo ("Tcnicas y materiales para el cierre cutneo en la cesrea" (Alderdice 2003)).
Adems de las variaciones en los aspectos individuales de la operacin como se detalla ms arriba, se han descrito varias tcnicas de cesrea completas. En esta revisin se evaluarn las comparaciones de dichas tcnicas completas. Las tcnicas descritas incluyen las siguientes. 1. La cesrea Pfannenstiel Se utiliza una incisin abdominal Pfannenstiel. La piel y la vaina subrrectal se abren de forma transversal con una diseccin losa. La vaina rectal se diseca libre de los msculos recto-abdominales subyacentes. El peritoneo se abre de forma longitudinal con una diseccin losa. El tero se abre con una histerotoma del segmento inferior transversal. La incisin uterina se cierra con dos capas de suturas continuas. Ambas capas peritoneales se cierran con suturas continuas. La fascia se cierra con suturas continuas o interrumpidas. La piel se cierra con una sutura intracutnea interrumpida o continua. 2. La cesrea tipo Pelosi (Capeless 2002; Wood 1999) Se utiliza una incisin abdominal Pfannenstiel. Para dividir los tejidos subcutneos y la fascia de forma transversal se utiliza el electrocauterio. Los msculos rectales se separan con una diseccin sin corte para brindar espacio a ambos dedos ndices, que liberan el fascial de forma vertical y transversal. El peritoneo se abre con una diseccin del dedo sin corte y todas las capas de la pared abdominal se estiran manualmente hasta la extensin de la incisin cutnea. La vejiga no se reeja hacia abajo. Se realiza una pequea incisin del segmento inferior transversal a travs del miometrio y se extiende lateralmente, con una curva hacia arriba, con una diseccin del dedo sin corte o una tijera. El beb es extrado mediante presin externa sobre el fundus, se administra oxitocina y se retira la placenta despus de la separacin espontnea. Se masajea el tero. Se cierra la incisin del miometrio con una sutura de bloqueo continua sin catgut crmico de una sola capa. No se realiza sutura en ninguna capa del peritoneo. La fascia se cierra con una sutura absorbible sinttica continua. Si la capa subcutnea es gruesa, se utilizan suturas absorbibles 3-0 interrumpidas para eliminar el espacio muerto. La piel se cierra con grapas. 3. La tcnica Joel-Cohen sta tcnica se diferencia de la tcnica descripta ms arriba en varios aspectos. Se utiliza la incisin abdominal "Joel-Cohen". sta es una incisin transversal derecha nicamente a travs de la piel, a 3 cm por debajo del nivel de las espinas ilacas superiores anteriores (ms elevada que la incisin Pfannenstiel). Los tejidos subcutneos se abren nicamente en el centro a 3 cm. Se realiza una incisin a la fascia de forma transversal en la lnea media y luego se extiende lateralmente con una diseccin del dedo sin corte (Joel-Cohen 1977; Wallin 1999). La diseccin del dedo se utiliza para separar los msculos rectales de forma vertical y abrir el peritoneo. Todas las capas de la pared abdominal se estiran manualmente para extender la incisin de la piel. La vejiga se reeja hacia abajo. Se realiza una incisin al miometrio de forma transversal en la lnea media pero sin cortar el saco amnitico, luego se abre y se extiende lateralmente con la diseccin del dedo. Las suturas
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interrumpidas se utilizan para el cierre del miometrio. Los estudios retrospectivos han sugerido que estos mtodos reducen el tiempo de operacin, la prdida de sangre y la estancia hospitalaria postoperatoria (Song 2006). Se han descrito varias modicaciones de la tcnica Joel-Cohen (Franchi 1998; Ferrari 2001; Stark 1995; Wallin 1999). 4. La tcnica Misgav-Ladach (Holmgren 1999) sta es una modicacin de la tcnica Joel-Cohen, desarrollada por Stark y colegas (Stark 1995). La incisin abdominal Joel-Cohen se utiliza (ver ms arriba), excepto para la fascia que se abre con un movimiento de empuje ciego de la punta de la tijera levemente abierta. El tero se abre como con el mtodo Joel-Cohen (ms arriba). La placenta se retira manualmente. El tero se extrae del cuerpo. La incisin del miometrio se cierra con una sutura continua de bloqueo de una sola capa. Las capas peritoneales no se suturan. La fascia se sutura con una sutura continua. La piel se cierra con dos o tres suturas de colchonero. Entre estas suturas, los bordes de la piel se acercan con las pinzas de Allis, que se dejan en el lugar durante cinco minutos mientras se retiran los pliegues. Las ventajas informadas incluyen tiempo de operacin menor (Darj 1999; Franchi 1998; Mathai 2002; Wallin 1999), menos uso de material de sutura (Bjorklund 2000), menos prdida de sangre intraoperatoria (Bjorklund 2000; Darj 1999; Wallin 1999) menos dolor postoperatorio (Darj 1999; Mathai 2002) menos infeccin de la herida (Franchi 1998), y menores adherencias en la repeticin de la ciruga (Stark 1995). Una comparacin retrospectiva descubri que la clsica incisin Joel-Cohen estaba asociada con una menor acumulacin de sangre postoperatoria en la pared abdominal, el saco de Douglas y el segmento uterino inferior que la incisin modicada, pero las diferencias eran pequeas (Malvasi 2007). 5. La cesrea extraperitoneal Histricamente el enfoque extraperitoneal se utilizaba para casos spticos en un intento por limitar la expansin de sepsis previo a la llegada de antibiticos efectivos (Haesslein 1980). Hoy en da su uso es poco usual. OBJETIVOS 1. Para comparar, con la mejor evidencia disponible, los efectos de los mtodos completos de cesrea no cubiertos en las revisiones de los aspectos individuales de la tcnica de cesrea. 2. Para resumir los resultados de las revisiones de los aspectos individuales de la tcnica de cesrea. Esto facilitar una revisin holstica de las tcnicas de cesrea con referencia cruzada lista a las revisiones de los aspectos individuales detalladas.
CRITERIOS PARA LA VALORACIN DE LOS ESTUDIOS DE ESTA REVISIN Tipos de estudios Se tuvieron en cuenta todos los ensayos controlados aleatorios publicados, no publicados y en curso que comparan el objetivo de realizar una cesrea por medio de diferentes tcnicas, excluyendo los aspectos individuales cubiertos en otras revisiones de Cochrane. Se excluyeron los ensayos cuasialeatorios. (p.ej., aquellos asignados al azar por fecha de nacimiento o nmero de hospital) del anlisis a menos que hubiera una razn establecida especca para su inclusin. Los estudios que fueron reportados nicamente de forma abstracta con informacin metodolgica inadecuada se incluyeron en la categora "Estudios en espera de evaluacin", para ser incluidos en los anlisis cuando se publiquen como informes completos, o se obtenga informacin adecuada de los autores. Los estudios se incluan si haba una ocultacin adecuada de la asignacin y las violaciones del tratamiento asignado y las exclusiones posteriores a la asignacin no eran sucientes para afectar materialmente los resultados. Tipos de participantes Mujeres embarazadas para un parto por cesrea electiva o de emergencia. Tipos de intervencin Cesrea realizada de acuerdo con una tcnica especicada con anterioridad, no cubierta por otras revisiones de los aspectos individuales de la tcnica de cesrea. Tipos de medidas de resultado Primario (1) Graves complicaciones intraoperatorias y postoperatorias, que incluyen dao orgnico, transfusin de sangre, sepsis signicativa, tromboembolismo, insuciencia orgnica, ingreso en la unidad de cuidados intensivos o muerte; (2) prdida de sangre (como lo denen los autores del ensayo); (3) transfusin sangunea. Secundario Medidas de resultado a corto plazo para la mujer (4) Tiempo de ciruga; (5) muerte de la madre; (6) ingreso en la unidad de cuidados intensivos; (7) nivel de hemoglobina o hematocrito postoperatorio, o cambio en los mismos; (8) anemia postoperatoria, como la denieron los autores del ensayo; (9) infeccin de heridas, como la denieron los autores del ensayo; (10) Hematoma en la herida; (11) dehiscencia de la herida; (12) endometritis tal como la denieron los autores del ensayo; (13) tiempo hasta la movilizacin; (14) tiempo hasta la ingesta oral;
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(15) tiempo hasta el retorno de la funcin intestinal; (16) tiempo hasta el inicio de la lactancia materna; (17) ebre tratada con antibiticos o como la denieron los investigadores; (18) repetidos procedimientos operatorios realizados en la herida; (19) dolor postoperatorio como lo calcularon los autores del ensayo; (20) uso de analgsicos, como lo denieron los autores del ensayo; (21) lactancia materna fallida (al momento del alta o como la denieron los autores del ensayo); (22) madre no satisfecha con la asistencia. Medidas de resultado a corto plazo para el beb (23) Tiempo desde la anestesia al parto; (24) tiempo desde la incisin cutnea al parto; (25) parto traumtico; (26) pH sanguneo del cordn menor que 7,2; (27) dcit de base de la sangre del cordn mayor que 15; (28) Puntuacin de Apgar menor a siete a los cinco minutos; (29) ingreso en la unidad de cuidados intensivos neonatales; (30) encefalopata; (31) muerte neonatal o perinatal. Medidas de resultado a largo plazo para la madre (32) Complicaciones de la herida a largo plazo p.ej. adormecimiento, formacin de queloide, hernia incisional; (33) dolor abdominal a largo plazo; (34) problemas de fertilidad futuros; (35) complicaciones en un futuro embarazo (p.ej.: rotura uterina, placenta previa, placenta acreta); (36) complicaciones en una futura ciruga (p.ej. formacin de adherencia). Uso de servicios sanitarios (37) Duracin de la estancia hospitalaria postoperatoria para la madre o el beb; (38) reingreso en el hospital de la madre o el beb, o ambos; (39) costes. Las medidas de resultado se incluan s eran clnicamente signicativas; medidas razonables adoptadas para minimizar el sesgo del observador; datos insucientes por su ausencia como para inuir materialmente en las conclusiones; datos disponibles para el anlisis de acuerdo a la asignacin original, independientemente de las violaciones del protocolo; datos disponibles en un formato adecuado para el anlisis. ESTRATEGIA DE BSQUEDA PARA LA IDENTIFICACIN DE LOS ESTUDIOS Se realizaron bsquedas en el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) (agosto 2007) mediante contacto con el Coordinador de Bsqueda de Ensayos.
El Coordinador de Bsqueda de Ensayos (Trials Search Co-ordinator) mantiene el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) que contiene ensayos identicados de: (1) Busquedas trimestrales del Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials - CENTRAL); (2) bsquedas mensuales en MEDLINE; (3) bsquedas manuales en 30 revistas y en los resmenes de congresos importantes; (4) bsqueda semanal de actualizacin permanente en 36 revistas adicionales adems de los avisos mensuales de correo electrnico de BioMed Central. Los detalles de las estrategias de bsqueda para CENTRAL y MEDLINE, la lista de revistas y de resmenes de congresos de la bsqueda manual y la lista de revistas revisadas mediante el servicio de actualizacin permanente se pueden encontrar en la seccin "Estrategias de bsqueda para la identicacin de estudios" dentro de la informacin editorial acerca del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group). A los ensayos identicados a travs de las actividades de bsqueda descritas anteriormente se les asigna un cdigo (o cdigos) que dependen del tema. Los cdigos estn ligados a los temas de revisin. El Coordinador de Bsqueda de Ensayos busca el registro para cada revisin mediante el uso de estos cdigos en lugar de las palabras clave. Adems, se realizaron bsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library 2007, nmero 3), utilizando los trminos de bsqueda "(caesarean OR cesarean) AND technique" y se realiz una bsqueda manual de las listas de referencias de todos los trabajos identicados. No se aplic ninguna restriccin de idioma. MTODOS DE LA REVISIN 1. Revisin de las tcnicas de cesrea Los ensayos clnicos en consideracin se evaluaron con respecto a lo apropiado de su inclusin y su calidad metodolgica sin tener en cuenta sus resultados. sta fue realizada por dos autores de la revisin de acuerdo con los criterios de elegibilidad preestablecidos. Los ensayos que cumplieron con los criterios de elegibilidad se evaluaron segn la calidad utilizando los siguientes criterios: 1. generacin de la secuencia de la asignacin aleatoria: A = adecuado, B = inadecuado, C = incierto; 2. ocultacin de la asignacin: A = adecuado, B = inadecuado, C = incierto;
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3. cegamiento de los participantes: A = s, B = inadecuado, C = no, D = sin informacin; 4. cegamiento de los encargados de la atencin mdica: A = s, B = inadecuado, C = no, D = sin informacin; 5. Cegamiento de la evaluacin de resultados: A = s, B = inadecuado, C = no, D = sin informacin; 6. cumplimiento con la intervencin asignada: A = menos que un incumplimiento del 3%, B = incumplimiento del 3% al 9,9%, C = incumplimiento del 10% o ms, D = incierto; 7. cumplimiento de los datos de seguimiento (que incluye cualquier prdida diferencial de participantes de cada grupo): A = menos del 3% de las participantes excluidas, B = entre el 3% y el 9,9% de las participantes excluidas, C = entre el 10% y el 19,9% de las participantes excluidas, D = 20% o ms de las participantes excluidas, E = incierto; 8. anlisis de los participantes en grupos asignados al azar: A = s, B = inadecuado, C = no, D = poco claro. Si una publicacin no informaba el anlisis de los participantes en sus grupos aleatorios, se intentaba reasignarla al grupo correcto (anlisis del tipo intencin de tratar [intention-to-treat analysi]). Si no haba suciente informacin en el informe para permitir esto, se contactaba a los autores y se solicitaban ms datos. Dos autores extrajeron datos de las publicaciones originales sobre los formularios de extraccin de datos. Las diferencias de opinin se resolvieron por medio de un debate o una derivacin al editor primario. Se combinaron los datos de diferentes ensayos si se consideraban lo sucientemente similares como para ser razonables. Se realizaron metanlisis por medio del uso de riesgos relativos como la medida del tamao del efecto para los resultados binarios, y las diferencias de media ponderada para las medidas de resultado continuas. Si los ensayos utilizaban diferentes maneras para evaluar la misma medida de resultado continuo (por ejemplo, el dolor), se empleaban diferencias medias estandarizadas. Se utiliz un metanlisis de efectos jos para la combinacin de datos del estudio si los ensayos fueron considerados lo sucientemente similares. Se investig la heterogeneidad por medio del clculo de estadsticas I (Higgins 2002 ), y si ste indicaba un alto nivel de heterogeneidad entre los ensayos incluidos en un anlisis (I mayor que el 50%), se utilizaba un metanlisis de efectos aleatorios para un resumen general. Cuando se encontraron niveles altos de heterogeneidad, se exploraron por medio de anlisis de subgrupos preespecicados y por anlisis de sensibilidad, con exclusin de los ensayos ms susceptibles al sesgo, en base a la evaluacin de calidad: los que tenan una ocultacin de la asignacin inadecuada (B o C); altos niveles de prdidas o exclusiones posteriores a la asignacin al azar (D); o evaluacin de los resultados no cegada, o cegamiento incierto de la evaluacin de resultados. Se planicaron los siguientes anlisis de subgrupos: (1) primero versus repetido versus combinado o cesrea no denida;
(2) trabajo de parto previo versus intraparto versus combinado o cesrea no denida; (3) prematuro versus a trmino versus combinado o cesrea no denida. Se deban investigar las diferencias en el efecto de la intervencin entre los subgrupos como fue descrito por Deeks 2001 (sujeto a nmeros sucientes de ensayos). 2. Resumen de otras revisiones de tcnicas de cesrea Las revisiones importantes se resumieron bajo los siguientes encabezados. 2.1. Ttulo 2.2. Autores de la revisin 2.3. Resultados principales de las intervenciones, con nmeros de ensayos y participantes 2.4. Implicaciones del autor para la prctica 2.5. Implicaciones del autor para la investigacin Se describi una tcnica de cesrea de rutina basada en la mejor evidencia, con especicaciones de las opciones cuando no se encontr una prueba clara para la preferencia, y con el cruce de las referencias de las revisiones relevantes de Cochrane. DESCRIPCIN DE LOS ESTUDIOS Se identicaron 23 estudios que comparaban diferentes tcnicas de cesrea en base a las estrategias de bsqueda. Se excluyeron cuatro ensayos de los anlisis porque la asignacin a los grupos de intervencin no estaba basada en la asignacin al azar en estos ensayos (Ansaloni 2001; Gaucherand 2001; Redlich 2001; Wallace 2000). Se pueden encontrar los detalles de estos estudios en la tabla "Caractersticas de los estudios excluidos". Cinco estudios (Behrens 1997; Decavalas 1997; Direnzo 2001; Hagen 1999; Meyer 1998b) se presentaron en varias reuniones y conferencias y contienen nicamente resultados limitados de los estudios. No se obtuvo la informacin ms detallada sobre los resultados de los ensayos arriba mencionados de los autores. Hubo alguna variacin en los detalles de las tcnicas denidas por los autores como "Joel-Cohen", Misgav-Ladach" y "Misgav-Ladach modicada". Todos estos mtodos se basan en los principios quirrgicos desarrollados por Joel-Cohen: la separacin sin corte de los tejidos junto con los planos de tejido naturales, con un mnimo de diseccin losa. Para esta revisin se clasic a los mtodos como subgrupos de las tcnicas de Joel-Cohen, de la siguiente manera: 'Joel-Cohen': Apertura uterina y abdominal Joel-Cohen; tero cerrado con suturas interrumpidas; peritoneo no cerrado; piel cerrada con sutura subcutnea (Wallin 1999b). 'Misgav-Ladach': apertura uterina y apertura abdominal Joel-Cohen; tero cerrado con sutura continua de una sola capa; peritoneo no cerrado; piel cerrada con suturas interrumpidas ampliamente espaciadas (Bjorklund 2000;
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Dani 1998; Darj 1999; Ferrari 2001; Heimann 2000; Li 2001; Mathai 2002; Moreira 2002). "Misgav-Ladach modicada": como las anteriores pero piel cerrada con sutura subcutnea (Koettnitz 1999) o varios mtodos de cierre de la piel (Xavier 2005) o tero cerrado con sutura continua sin bloqueo de una sola capa (Franchi 1998b; Franchi 2002); o peritoneo visceral no abierto y tero cerrado con dos capas de sutura sin bloqueo (Li 2001); o la piel abierta al nivel de la incisin Pfannenstiel por razones estticas (Heimann 2000). Once estudios han investigado la diferencia entre las tcnicas de cesrea de Joel-Cohen y Pfannenstiel (Dani 1998; Darj 1999; Ferrari 2001; Franchi 1998b; Franchi 2002; Heimann 2000; Koettnitz 1999; Li 2001; Mathai 2002; Wallin 1999b; Xavier 2005). Dos estudios (Bjorklund 2000; Moreira 2002) compararon la tcnica Misgav-Ladach con las cesreas tradicionales (incisin abdominal de la lnea media inferior). Un estudio compar las tcnicas de cesrea extraperitoneal e intraperitoneal (Mokgokong 1974). Los detalles de los estudios citados anteriormente estn disponibles en la tabla "Caractersticas de los estudios incluidos". CALIDAD METODOLGICA La calidad metodolgica de los estudios incluidos fue variable. La ocultacin de la asignacin no fue clara en tres estudios (Dani 1998; Moreira 2002; Xavier 2005). Debido al tipo de intervencin, el equipo quirrgico no estaba cegado a la intervencin asignada. La asignacin se revelaba usualmente inmediatamente antes de que se realizara la incisin cutnea. La evaluacin de las variables intraoperatorias (p.ej. tiempo de operacin, prdida de sangre estimada) puede haber estado sujeta al sesgo. Sin embargo, la evaluacin de los resultados postoperatorios; (p.ej. morbilidad febril, dolor, requerimientos analgsicos) estaba cegada en la mayora de los estudios. Para una descripcin ms detallada de la calidad de los ensayos individuales, consultar tabla 'Caractersticas de los estudios incluidos'. Un estudio con la ocultacin de la asignacin inadecuada y con diferencias sin explicacin en los nmeros de grupo (Mokgokong 1974) fue includo por inters histrico. RESULTADOS Cesrea de Joel-Cohen versus Pfannenstiel Once estudios compararon la cesrea de Joel-Cohen" y Pfannenstiel. stos fueron clasicados en subgrupos como se detalla a continuacin: Joel-Cohen (Mathai 2002; Wallin 1999b); Misgav-Ladach (Dani 1998; Darj 1999; Ferrari 2001;
Li 2001); y Modied Misgav-Ladach (Franchi 1998b; Franchi 2002; Heimann 2000; Koettnitz 1999; Li 2001; Xavier 2005). Se informaron graves complicaciones en slo cuatro ensayos (913 mujeres) en las comparaciones entre la Misgav-Ladach modicada versus Pfannenstiel, y eran muy pocas para un anlisis estadstico signicativo (tres y dos eventos respectivamente). Se informaron nicamente tres transfusiones de sangre, todas en los grupos de Misgav-Ladach modicada (tres ensayos, 681 mujeres). La ciruga de Joel-Cohen se asoci con: menos prdida de sangre en todos los ensayos [cinco ensayos, 481 mujeres; diferencia de medias ponderada (DMP) 64,45 ml; intervalo de conanza (IC) del 95%: -91.34 a -37.56 ml). tiempo de operacin ms corto en todos los ensayos. Hubo una heterogeneidad signicativa en la magnitud de la reduccin (F = 93%). La DMP total fue una reduccin de 18,65 minutos (cinco ensayos, 481 mujeres; IC del 95%: -24,84 a -12,45 minutos; modelo de efectos aleatorios). sin una diferencia total en la ocurrencia de infecciones de las heridas (seis ensayos, 1 071 mujeres, considerable heterogeneidad). ninguna diferencia en el nivel de hematocrito postoperatorio y una reduccin mayor de hemoglobina que 4 g %, informado en un ensayo cada (Heimann 2000; Mathai 2002), (101 mujeres y 240 mujeres respectivamente). una tendencia a un hematoma de la herida aumentado en el subgrupo Misgav-Ladach modicada en un ensayo en el que se inform esta medida de resultado (Heimann 2000; (240 mujeres; riesgo relativo [RR] 1,80; IC del 95%: 0,98 a 3,31). no hubo una diferencia signicativa en la dehiscencia de la herida (tres ensayos, 468 mujeres). datos inadecuados sobre endometritis, informados nicamente en una mujer, en el grupo Pfannenstiel (tres ensayos, 767 mujeres). despus de la ciruga, una reduccin general con una signicativa heterogeneidad (I = 90%) in tiempo a la ingesta oral (cinco ensayos, 481 mujeres; DMP -3,92; IC del 95%: -7,13 a -0,71 horas; modelo de efectos aleatorios). no hubo una diferencia signicativa en el tiempo de retorno de la funcin del intestino. no hubo una diferencia signicativa en el tiempo de movilizacin (dos ensayos, 208 mujeres; DMP -2,86; IC del 95%: -11,29 a 5,56) o en el tiempo para la iniciacin de la lactancia materna (un ensayo, 101 mujeres). menos ebre, tratada con antibiticos o como lo denieron los autores del ensayo (ocho ensayos:, 1 412 mujeres; RR 0,47; IC del 95%: 0,28 a 0,81). datos insucientes sobre la repeticin del procedimiento quirrgico en la herida, que se informaron nicamente en
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una mujer, en el grupo Pfannenstiel (dos ensayos, 228 mujeres). menor duracin del dolor postoperatorio (dos comparaciones de un ensayo, 172 mujeres; DMP -14,18 horas; IC del 95%: -18,31 a -10,04 horas) y un uso menor de analgesia, denido como el nmero de inyecciones de analgsicos (Darj 1999) o el nmero de inyecciones en las primeras 24 horas (Mathai 2002)(dos ensayos, 151 mujeres; DMP -0,92; IC del 95%: -1,20 a -0,63). tiempo ms corto desde la incisin cutnea al nacimiento del beb en todos los ensayos. Hubo una heterogeneidad signicativa en la magnitud de la reduccin (F = 89.5%). La DMP total fue una reduccin de 3,84 minutos (cinco ensayos, 575 mujeres; IC del 95%: -5,41 a -2,27 minutos; modelo de efectos aleatorios). datos insucientes sobre la puntuacin de Apgar baja (dos puntuaciones bajas en el grupo Pfannenstiel, un ensayo, 158 mujeres). Ninguna diferencia en el ingreso a la unidad neonatal de cuidados intensivos (un ensayo, 310 mujeres). Anlisis de subgrupos Se inform que cuatro ensayos se limitaban a mujeres a las que se les realizaba una ciruga abdominal por primera vez (Darj 1999; Ferrari 2001; Mathai 2002; Wallin 1999b). Los resultados fueron similares a los de todos los ensayos. No haba datos sucientes para realizar anlisis de subgrupos adicionales. Misgav-Ladach versus tradicional (incisin abdominal de la lnea media inferior) Slo uno de los dos ensayos aport datos para cada medida de resultado (Bjorklund 2000; Moreira 2002). El mtodo Misgav-Ladach se asoci con la prdida de sangre reducida (339 mujeres; DMP -93,00; IC del 95%: -132,72 a -53,28 ml); tiempo de operacin (339 mujeres; DMP -7,30; IC del 95%: -8,32 a -6,28 minutos); tiempo hasta la movilizacin (339 mujeres; DMP -16,06; IC del 95%: -18,22 a -13,90 horas); y duracin de la estancia postoperatoria para la madre (339 mujeres; DMP -0,82; IC del 95%: -1,08 a -0,56 das). No hubo diferencias signicativas en la anemia postoperatoria (339 mujeres); infeccin de la herida (339 mujeres); dehiscencia de la herida (339 mujeres); endometritis (400 mujeres); o ebre (339 mujeres). Mtodos Misgav-Ladach versus Misgav-Ladach modicado En un ensayo (Li 2001; 116 mujeres), el mtodo Misgav-Ladach se asoci con un tiempo mayor desde la incisin cutnea al nacimiento del beb (DMP 2,10; IC del 95%: 1,10 a 3,10 minutos), y sin diferencias signicativas en la prdida de sangre, el tiempo de la ingesta oral, el tiempo de retorno de la funcin intestinal, puntuacin del dolor postoperatorio, o duracin de la estancia postoperatoria de la madre. Cesrea extraperitoneal versus intraperitoneal
Un estudio con una insuciente metodologa de acuerdo a los niveles actuales compar las tcnicas de cesrea extraperitoneal e intraperitoneal (Mokgokong 1974). Una mujer de las 173 tuvo graves complicaciones durante o despus de una cesrea extraperitoneal en comparacin con 12 mujeres de las 239 en el grupo que tuvo una C intraperitoneal (RR 0,12; IC del 95%: 0,02 a 0,88). La tasa de mortalidad materna no diri entre los dos grupos. La frecuencia de ebre tratada con antibiticos fue ms baja en el grupo de cesrea extraperitoneal (RR 0,42; IC del 95%: 0,27 a 0,65). No hubo una diferencia signicativa en el nmero de pacientes sometidas a nuevos procedimientos en la herida. Los resultados deben ser interpretados con cautela. Anlisis de subgrupos Hubo escasos ensayos que se limitaron a los subgrupos homogneos de cesrea a trmino, con trabajo de parto previo y primaria para el anlisis signicativo de los subgrupos. La tabla 01 muestra un resumen de las revisiones de Cochrane sobre varios aspectos de las tcnicas de cesrea. Adems se resumi una tcnica de C de rutina basada en la evidencia de estas revisiones en la tabla 02. DISCUSIN En esta revisin se realizaron cuatro grupos de comparacin. No se identic ningn estudio que investigara la cesrea de tipo Pelosi. La calidad metodolgica de 14 ensayos incluidos fue en general satisfactoria. Sin embargo, alguna evaluacin de resultados estuvo sujeta al sesgo, p.ej. el tiempo de operacin, la prdida de sangre. Los datos informados en los estudios que comparaban las tcnicas de cesrea estaban limitados a medidas de resultado a corto plazo. Estos resultados favorecieron las tcnicas Joel-Cohen (Joel-Cohen, Misgav-Ladach y Misgav-Ladach modicada) por encima de las tcnicas Pfannenstiel en relacin a medidas de resultado tales como el tiempo desde la incisin cutnea al parto del beb, el tiempo de operacin, la prdida de sangre, la puntuacin del dolor postoperatorio, el nmero de inyecciones de analgsicos, el tiempo de la ingesta oral, el tiempo de retorno de la funcin intestinal, el tiempo para la movilizacin, la morbilidad febril y la estancia postoperatoria de la madre; y por encima de las tcnicas de cesrea tradicionales (incisin abdominal de la lnea media inferior) en relacin a medidas de resultado tales como el tiempo de operacin, el tiempo hasta la movilizacin y la estancia hospitalaria postoperatoria. La nica ventaja de las tcnicas Misgav-Ladach modicadas por sobre la tcnica Misgav-Ladach era un tiempo ms corto desde la incisin cutnea hasta la extraccin del beb. La cesrea extraperitoneal en mujeres con sepsis abdominal es de inters histrico. No hubo datos sobre los ensayos slidos que facilitara una evidencia able.
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Ninguno de los ensayos incluidos ha facilitado datos sobre la satisfaccin de la madre, el uso de los servicios de salud y medidas de resultado a largo plazo, particularmente con respecto a la fertilidad posterior, la morbilidad por adherencia de la placenta y la rotura uterina. Darj 1999 inform que no hubo diferencias signicativas entre la operacin Misgav-Ladach y la Pfannenstiel, evaluadas por las mujeres, con respecto a la evaluacin de la cicatriz, pero no se proporcion ningn dato. CONCLUSIONES DE LOS AUTORES Implicaciones para la prctica Las pruebas disponibles sugieren que las tcnicas Joel-Cohen (Joel-Cohen, Misgav-Ladach y Misgav-Ladach modicada) tienen ventajas por encima de las tcnicas de cesrea Pfannenstiel y tradicional (lnea media inferior) en relacin a lasmedidas de resultado a corto plazo. No existe ninguna prueba en relacin a medidas de resultado a largo plazo. Dadas las pruebas de varios estudios observacionales de que el cierre uterino de una sola capa puede asociarse con un riesgo aumentado de rotura uterina en embarazos posteriores (ver antecedentes), se justica el uso del cierre uterino de doble capa dependiendo de los resultados de los ensayos aleatorios, particularmente en sitios con pocos recursos donde las mujeres pueden no tener acceso a una cesrea en embarazos posteriores. Los resultados de esta revisin junto con otras revisiones de Cochrane sobre los aspectos especcos de la tcnica de cesrea y otras cirugas abdominales apoyan las siguientes opciones para una cesrea de rutina. Sin extraccin; o corte del vello previo a la operacin o cremas depilatorias el da de la ciruga o el da anterior (sin rasurado) Sin antisptico especco para un bao preoperatorio Prolaxis antibitica con ampicilina o una cefalosporina de primera generacin Anestesia espinal, epidural o general Clorhexidina para la preparacin de la piel Guantes dobles Apertura de la pared abdominal inferior transversal y apertura uterina por medio de los mtodos basados en Joel-Cohen Extraccin de la placenta con traccin del cordn Reparacin abdominal interior o exterior del tero El cierre uterino con sutura con bloqueo continua de una sola capa o interrumpida no tiene benecios a corto plazo. Sin embargo, las pruebas de los estudios observacionales de un aumentado riesgo de rotura de la cicatriz favorece el uso de un cierre de doble capa dependiendo de las pruebas sobre esta medida de resultado de los ensayos aleatorios Sin cierre de ambas capas peritoneales En estas revisiones no se evual ningn mtodo especco para el cierre de la fascia Cierre de los tejidos subcutneos
Sin drenaje de rutina de los tejidos subcutneos Cierre de la piel con suturas subcuticulares o interrumpidas, grapas o adhesivo tisular Sin restriccin de lquidos orales despus de la ciruga Los mtodos basados en Joel-Cohen estn ilustrados en un programa de video sobre la Biblioteca de Salud Reproductiva de la Organizacin Mundial de la Salud (rhlibrary.com). Cuando no se mostraron benecios claros de un mtodo por encima de otro, la opcin puede haber sido inuenciada por el contexto clnico. Por ejemplo, en un mbito con recursos limitados donde se practican muchas cesreas por equipos en formacin, una opcin coste-efectiva puede ser un analgsico espinal y los mtodos quirrgicos Joel-Cohen, que requieren nicamente dos largos de material de sutura para la operacin y un cierre de doble capa del tero. Implicaciones para la investigacin Se necesita una investigacin ms a fondo de las medidas de resultado a largo plazo (en particular el dolor a largo plazo, la fertilidad, la morbilidad por adherencia de la placenta y rotura del tero) despus de diferentes tcnicas de cesrea. Ser de utilidad el estudio de la satisfaccin de las mujeres y los cuidadores con la ciruga y con el uso de las instalaciones para la asistencia mdica, as como tambin los estudios que comparen el mtodo Joel-Cohen original con la tcnica Misgav-Ladach. Existe una falta de investigaciones sobre las tcnicas para la repeticin de cesrea. AGRADECIMIENTOS Denise Atherton, Lynn Hampson y Sonja Henderson por el apoyo tcnico. Como parte del proceso previo a la publicacin, esta revisin ha sido comentada por tres colegas (un editor y dos asesores que no forman parte del equipo editorial), un miembro del panel internacional de consumidores del Grupo de Embarazo y Parto y el asesor estadstico del Grupo. POTENCIAL CONFLICTO DE INTERS Matthews Mathai es autor de un ensayo aleatorio sobre las incisiones abdominales para una cesrea. M Mathai y A Shah pertenecen al personal de la Organizacin Mundial de la Salud. Las opiniones expresadas son las de los autores y no reejan necesariamente las de la Organizacin Mundial de la Salud. FUENTES DE FINANCIACIN Recursos externos (GJH) World Health Organization (long-term Institutional Development Grant) SWITZERLAND
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NHS Programme for Research and Development UK
Recursos internos (GJH) Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health SOUTH AFRICA
REFERENCIAS
Referencias de los estudios incluidos en esta revisin Bjorklund 2000 {published data only} Bjorklund K, Kimaro M, Urassa E, Lindmark G. Introduction of the Misgav Ladach caesarean section at an African tertiary centre: a randomised control trial. BJOG: an international journal of obstetrics and gynaecology 2000;107(2):209-16. Dani 1998 {published data only} Dani C, Reali MF, Oliveto R, Temporin GF, Bertini G, Rubaltelli FF. Short-term outcome of newborn infants born by a modied procedure of cesarean section: a prospective randomized study. Acta Obstetricia et Gynecologica Scandinavica 1998;77:929-31. Darj 1999 {published data only} Darj E, Nordstrom ML. The misgav ladach method for cesarean section compared to the pfannenstiel method. Acta Obstetricia et Gynecologica Scandinavica 1999;78(1):37-41. 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 1998b {published data only} *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;15:589-94. 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(1 Pt 2):S31. Franchi 2002 {published data only} *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 M, Raio L, Naro Di E, Balestreri D, Miglierina M, et al. Pfannestiel or joel-cohen incision at cesarean delivery: a randomized clinical trial [abstract]. American Journal of Obstetrics and Gynecology 2001;184(1):S166. Heimann 2000 {published data only} Heimann J, Hitschold T, Muller K, Berle P. Randomized trial of the modied misgav-ladach and the conventional pfannensteil techniques for cesarean section. Geburtshilfe und Frauenheilkunde 2000;60:242-50. Koettnitz 1999 {published data only} Koettnitz F, Feldkamp E, Werner C. 'The Soft-Sectio' - An alternative to the classical method. Zentralblatt fur Gynakologie 1999;121:287-9. Li 2001 {published data only} Li M, Zou L, Zhu J. Study on modication of the Misgav Ladach method for cesarean section. Journal of Tongji Medical University 2001;21(1):75-7. Mathai 2002 {published data only} Mathai M, Ambersheth S, George A. Comparison of two transverse abdominal incisions for cesarean delivery. International Journal of Gynecology & Obstetrics 2002;78:47-9. Pgina 11 Mokgokong 1974 {published data only} Mokgokong ET, Crichton D. Extraperitoneal lower segment caesarean section for infected cases. A reappraisal. South African Medical Journal 1974;48:788-90. Moreira 2002 {published data only} Moreira P, Moreau JC, Faye ME, Ka S, Kane Gueye SM, Faye EO, et al. Comparison of two cesarean techniques: classic versus misgav ladach cesarean. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2002;31(6):572-6. Wallin 1999b {published data only} *Wallin G, Fall O. Modied joel-cohen technique for caesarean delivery. British Journal of Obstetrics and Gynaecology 1999;106(3):221-6. Wallin G, Fall O. Modied joel-cohen technique for caesarean section. A prospective randomised study. Acta Obstetricia et Gynecologica Scandinavica 1997;76 Suppl(167:2):24. Xavier 2005 {published data only} Ayres-de-Campos D, Patricio B. Modications to the misgav ladach technique for cesarean section [letter]. Acta Obstetricia et Gynecologica Scandinavica 2000;79:326-7. *Xavier P, Ayres-De-Campos D, Reynolds A, Guimaraes M, Costa-Santos C, Patricio B. The modied misgav-ladach versus the pfannenstiel-kerr technique for cesarean section: a randomized trial. Acta Obstetricia et Gynecologica Scandinavica 2005;84(9):878-82. 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. Referencias de los estudios excluidos de esta revisin Ansaloni 2001 Ansaloni L, Brundisini R, Morino G, Kjura A. Prospective, randomized, comparative study of Misgav Ladach versus traditional Cesarean section at Nazareth Hospital, Kenya. World of Surgery 2001;25(9):1164-72. Gaucherand 2001 Gaucherand P, Bessai K, Sergeant P, Rudigoz R-C. Towards simplied cesarean section [Vers une simplication de l'operation cesarienne?]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2001;30:348-52. Redlich 2001 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. Zentralblatt fur Gynakologie 2001;123(11):638-43. Wallace 2000 Wallace RL, Eglinton GS, Yonekura ML, Wallace TM. Extraperitoneal cesarean section: a surgical form of infection prophylaxis?. American Journal of Obstetrics and Gynecology 1984;148(2):172-7.
Referencias de los estudios en espera de evaluacin Behrens 1997 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. Decavalas 1997 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 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. Hagen 1999 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. Le D 2007 Le D R, Bernardini M, Agostini A, Mazouni C, Shojai R, Blanc B, Gamerre M, Bretelle F. Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision [Etude prospective comparative entre les techniques de cesarienne de Joel-Cohen et de Mouchel]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 2007;36(5):447-50. Meyer 1998b 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. Referencias adicionales ACOG 2001 American College of Obstetricians and Gynecologists. Optimal goals for anesthesia care in obstetrics. ACOG Committee Opinion #256. Washington, DC: American College of Obstetricians and Gynecologists, 2001. Alderdice 2003 Alderdice F, McKenna D, Dornan J. Techniques and materials for skin closure in caesarean section. In: Cochrane Database of Systematic Reviews, 2, 2003. 10.1002/14651858.CD003577. Ananth 1997 Ananth CV, Smulian JC, Vintzileos AM. The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. American Journal of Obstetrics and Gynecology 1997;177:1071-8. Bamigboye 2003 Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section. In: Cochrane Database of Systematic Reviews, 4, 2003. 10.1002/14651858.CD000163. Belizan 1999 Belizan J, Althabe F, Barros F, Alexander S. Rates and implication of cesarean sections in Latin America: ecological study. BMJ 1999;319:1397-402. Betran 2007 Betran AP, Merialdi M, Lauer JA, Bging-Shun W, Thomas J, Van Look P, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 2007;21(2):98-113. Beukens 2001 Beukens P. Over-medicalisation of maternal care in developing countries. In: De Brouwere, Van Lerberghe, editor(s). Safe motherhood strategies: a review of the evidence. Antwerp: ITG Press, 2001:195-206.
Brocklehurst 2002 Brocklehurst P. Interventions for reducing the risk of mother-to-child transmission of HIV infection. In: Cochrane Database of Systematic Reviews, 1, 2002. 10.1002/14651858.CD000102. Bujold 2002 Bujold E, Bujold C, Hamilton EF, Harel F, Gauthier RJ. The impact of a single-layer or double-layer closure on uterine rupture. American Journal of Obstetrics and Gynecology 2002;186(6):1326-30. Bhague 2002 Bhague DP, Victoria CG, Barros FC. Consumer demand for cesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth control study linking ethnographic and epidemiological methods. BMJ 2002;324(7343):942-5. Cai 1998 Cai WW, Marks JS, Chen CH, Zhuang YX, Morris L, Harris JR. Increased caesarean section rates and emerging patterns of health insurance in Shanghai, China. American Journal of Public Health 1998;88:777-80. Capeless 2002 Capeless E, Damron DP. Cesarean delivery. UpToDate electronic library; www.uptodate.com, (accessed 10 February 2002) Clarke 1985 Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstetrics & Gynecology 1985;66(1):89-92. Collins 1999 Collins SL, Moore RA, McQuay HJ, Wiffen PJ, Edwards JE. Single dose oral ibuprofen and diclofenac for postoperative pain. In: Cochrane Database of Systematic Reviews, 1, 1999. 10.1002/14651858.CD001548. Cousins 1996 Cousins LM, Teplick FB, Poeltler DM. Pre-cesarean blood bank orders: a safe and less expensive approach. Obstetrics & Gynecology 1996;87:912-6. Crowther 1996 Crowther CA. Caesarean delivery for the second twin. In: Cochrane Database of Systematic Reviews, 1, 1996. 10.1002/14651858.CD000047. Cyna 2006 Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. In: Cochrane Database of Systematic Reviews, 4, 2006. 10.1002/14651858.CD002251.pub2. Dandolu 2006 Dandolu V, Raj J, Harmanli O, Lorico A, Chatwani AJ. Resident education regarding technical aspects of cesarean section. Journal of Reproductive Medicine 2006;51(1):49-54. Deeks 2001 Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG, editor(s). Systematic reviews in health care: meta-analysis in context. London: BMJ Books, 2001. Duff 1986 Duff P. Pathophysiology and management of postcesarean endomyometritis. Obstetrics & Gynecology 1986;67:269-76. Dumont 2001 Dumont A, de Bernis L, Bouvier-Colle MH, Breart G. Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review. Lancet 2001;358:1328-33. Durnwald 2003 Durnwald C, Mercer B. Uterine rupture, perioperative and perinatal morbidity after single-layer and double-layer closure at cesarean delivery. American Journal of Obstetrics and Gynecology 2003;189(4):925-9.
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Edwards 2000 Edwards JE, Moore RA, McQuay HJ. Single dose oxycodone and oxycodone plus paracetamol (acetominophen) for acute postoperative pain. In: Cochrane Database of Systematic Reviews, 2, 2000. 10.1002/14651858.CD002763. Efekhar 2000 Efekhar K, Steer P. Caesarean section controversy. Women choose caesarean section. BMJ 2000;320:1073-4. Enkin 2006 Enkin MW, Wilkinson C. Single versus two layer suturing for closing the uterine incision at Caesarean section. In: Cochrane Database of Systematic Reviews, 3, 2006. 10.1002/14651858.CD000192.pub2. Feldman 1985 Feldman GB, Freiman JA. Prophylactic cesarean section at term?. New England Journal of Medicine 1985;312:1264-7. Franchi 1998 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;15:589-94. Frigoletto 1980 Frigoletto FD Jr, Ryan KJ, Phillippe M. Maternal mortality rate associated with cesarean section: an appraisal. American Journal of Obstetrics and Gynecology 1980;136:969-70. Gates 2002 Gates S, Brocklehurst P, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. In: Cochrane Database of Systematic Reviews, 2, 2002. 10.1002/14651858.CD001689. Gherman 1999 Gherman RB, Goodwin TM, Leung B, Byrne JD, Hethumumi R, Montoro M. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstetrics & Gynecology 1999;94(5 Pt 1):730-4. Grant 2001 Grant A, Glazener CMA. Elective caesarean section versus expectant management for delivery of the small baby. In: Cochrane Database of Systematic Reviews, 2, 2001. 10.1002/14651858.CD000078. Gyam 2006 Gyam C, Juhasz G, Gyam P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. Journal of Maternal-Fetal & Neonatal Medicine 2006;19(10):639-43. Haesslein 1980 Haesslein HC, Goodlin RC. Extraperitoneal cesarean section revisited. Obstetrics & Gynecology 1980;55:181-3. Hamilton 2001 Hamilton EF, Bujold E, McNamara H, Gauthier R, Platt RW, et al. Dystocia among women with symptomatic uterine rupture. American Journal of Obstetrics and Gynecology 2001;184:620-4. Hayakawa 2006 Hayakawa H, Itakura A, Mitsui T, Okada M, Suzuki M, Tamakoshi K, et al. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstetricia et Gynecologica Scandinavica 2006;85(4):429-34. Higgins 2002 Higgins J, Thompson SG. Quantifying heterogeneity in a meta-analysis. Statistics in Medicine 2002;21:1539-58. Hofmeyr 1995 Hofmeyr GJ. Caesarean section. In: Chamberlain GVP, editor(s). Turnbull's obstetrics. Churchill Livingstone, 1995.
Hofmeyr 1998 Hofmeyr GJ, Kulier R. Operative versus conservative management for 'fetal distress' in labour. In: Cochrane Database of Systematic Reviews, 2, 1998. 10.1002/14651858.CD001065. Hofmeyr 2003 Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. In: Cochrane Database of Systematic Reviews, 2, 2003. 10.1002/14651858.CD000166. Hohlagschwandtn 2001 Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder ap at cesarean necessary? A randomized trial. Obstetrics & Gynecology 2001;98:1089-92. 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. Hopkins 1999 Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for caesarean section. In: Cochrane Database of Systematic Reviews, 2, 1999. 10.1002/14651858.CD001136. Houston 2000 Houston MC, Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. American Journal of Obstetrics and Gynecology 2000;182:1033-5. How 2000 How HY, Harris BJ, Pietrantoni M, Evans JC, Dutton S, Khoury J, et al. Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?. American Journal of Obstetrics and Gynecology 2000;182(2):1527-34. Iffy 1979 Iffy L, Kaminetzky HA, Maidman JE, Lindsay J, Arrata WS. Control of perinatal infection by traditional preventive measures. Obstetrics & Gynecology 1979;54(4):403-11. Jacobs-Jokhan 2004 Jacobs-Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. In: Cochrane Database of Systematic Reviews, 4, 2004. 10.1002/14651858.CD000085.pub2. James 2001 James D. Caesarean section for fetal distress. BMJ 2001;322:1316-7. Joel-Cohen 1977 Joel-Cohen S. Abdominal and vaginal hysterectomy: new techniques based on time and motion studies. London: William Heinemann Medical Books, 1977. Kenepp 1982 Kenepp NB, Kumar S, Shelley WC, Stanley CA, Gabbe SG, Gutsche BB. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet 1982;1(8282):1150-2. Lavender 2006 Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GML. Caesarean section for non-medical reasons at term. In: Cochrane Database of Systematic Reviews, 3, 2006. 10.1002/14651858.CD004660.pub2. Lilford 1990 Lilford RJ, van Coeverden de Groot HA, Moore PJ, Bingham P. The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances. British Journal of Obstetrics and Gynaecology 1990;97:883-92. Lurie 2003 Lurie S, Glezerman M. The history of cesarean technique. American Journal of Obstetrics and Gynecology 2003;189(6):1803-6.
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Luthy 1991 Luthy DA, Wardinsky T, Shurtleff DB, Hollenbach KA, Hickok DE, Nyberg DA, et al. Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally. New England Journal of Medicine 1991;324(10):662-6. Lydon-Rochelle 2001a Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth. Obstetrics & Gynecology 2001;97:765-9. Lydon-Rochelle 2001b Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. New England Journal of Medicine 2001;345(1):3-8. Lyon 1987 Lyon JB, Richardson AC. Careful surgical technique can reduce infectious morbidity after cesarean section. American Journal of Obstetrics and Gynecology 1987;157:557-62. MacKenzie 2001 MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ 2001;322:1334-5. Malvasi 2007 Malvasi A, Tinelli A, Serio G, Tinelli R, Casciaro S, Cavallotti C. Comparison between the use of the Joel-Cohen incision and its modication during Stark's cesarean section. Journal of Maternal-Fetal & Neonatal Medicine 2007;20(10):757-61. Mangesi 2002 Mangesi L, Hofmeyr GJ. Early compared with delayed oral uids and food after caesarean section. In: Cochrane Database of Systematic Reviews, 3, 2002. 10.1002/14651858.CD003516. Mathai 2007 Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. In: Cochrane Database of Systematic Reviews, 1, 2007. 10.1002/14651858.CD004453.pub2. Menacker 2001 Menacker F, Curtin SC. Trends in cesarean birth and vaginal birth after previous cesarean, 1991-99. National Vital Statistics Reports 2001; Vol. 49, issue 13:1-16. Meyer 1998 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):S80. Moore 1998 Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose paracetamol (acetaminophen), with and without codeine, for postoperative pain. In: Cochrane Database of Systematic Reviews, 4, 1998. 10.1002/14651858.CD001547. Moore 2007 Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. In: Cochrane Database of Systematic Reviews, 3, 2007. 10.1002/14651858.CD003519.pub2. Murray 1997 Murray SF, Pradenas FS. Health sector reform and rise of caesarean birth in Chile. Lancet 1997;349:64. Naumann 1995 Naumann RW, Hauth JC, Owen J, Hodgekins PM, Lincoln T. Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Obstetrics & Gynecology 1995;85(3):412-6. Neilson 2003a Neilson JP. Interventions for suspected placenta praevia. In: Cochrane Database of Systematic Reviews, 2, 2003. 10.1002/14651858.CD001998.
Neilson 2003b Neilson JP. Interventions for treating placental abruption. In: Cochrane Database of Systematic Reviews, 1, 2003. 10.1002/14651858.CD003247. Ng 2004 Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural anaesthesia for caesarean section (Protocol for a Cochrane Review). In: Cochrane Database of Systematic Reviews, 2, 2004. 10.1002/14651858.CD003765.pub2. Nielsen 1984 Nielsen TF, Hokegard KH. Cesarean section and intraoperative surgical complications. Acta Obstetricia et Gynecologica Scandinavica 1984;63:103-8. Oguz 1998 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. Owen 1994 Owen J, Andrews WW. Wound complications after cesarean sections. Clinical Obstetrics and Gynecology 1994;37:842-55. Pai 1999 Pai M, Sundaram P, Radhakrishnan KK, Thomas K, Muliyil JP. A high rate of caesarean sections in an afuent section of Chennai: is it cause for concern?. National Medical Journal of India 1999;12:156-8. Pattinson 1997 Pattinson RC, Farrell E. Pelvimetry for fetal cephalic presentations at term. In: Cochrane Database of Systematic Reviews, 2, 1997. 10.1002/14651858.CD000161. Peskett 1973 Peskett WGH. Antacids before obstetric anesthesia. Anesthesia 1973;28:509. Petitti 1985 Petitti DB. Maternal mortality and morbidity in cesarean section. Clinical Obstetrics and Gynecology 1985;28:763-9. Rainaldi 1998 Rainaldi MP, Tazzari PL, Scagliarini G, Borghi B, Conte R. Blood salvage during caesarean section. British Journal of Anaesthesia 1998;80:195-8. Ranney 1975 Ranney B, Stanage WF. Advantages of local anesthesia for cesarean section. Obstetrics & Gynecology 1975;48(2):163-7. Ransom 1999 Ransom SB, Fundaro G, Dombrowski MP. Cost-effectiveness of routine blood type and screen testing for cesarean section. Journal of Reproductive Medicine 1999;44:592-4. Schuitemaker 1997 Schuitemaker N, van Roosmalen J, Dekker G, van Dongen P, van Geijn H, Gravenhorst JB. Maternal mortality after cesarean section in The Netherlands. Acta Obstetricia et Gynecologica Scandinavica 1997;76(4):332-4. Silver 2000 Silver RM, Porter TF, Branch DW, Esplin MS, Scott JR. Neonatal alloimmune thrombocytopenia: antenatal management. American Journal of Obstetrics and Gynecology 2000;182(5):1233-8. Simpson 2001 Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG: an international journal of obstetrics and gynaecology 2001;108:56-60.
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Singata 2002 Singata M, Tranmer JE. Restricting oral uid and food intake during labour. In: Cochrane Database of Systematic Reviews, 4, 2002. 10.1002/14651858.CD003930. Smaill 2002 Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. In: Cochrane Database of Systematic Reviews, 3, 2002. 10.1002/14651858.CD000933. Song 2006 Song SH, Oh MJ, Kim T, Hur JY, Saw HS, Park YK. Finger-assisted stretching technique for cesarean section. International Journal of Gynecology & Obstetrics 2006;92(3):212-6. Stark 1995 Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of combinations of procedures in cesarean section. International Journal of Gynecology & Obstetrics 1995;48(3):273-6. Thomas 2001 Thomas J, Paranjothy S. The National Sentinel Caesarean Section Audit report. London: Royal College of Obstetricians and Gynaecologists, 2001. Tufnell 2001 Tuffnell DJ, Wilkinson K, Beresford N. Interval between decision and delivery by caesarean section-are current standards achievable? Observational case series. BMJ 2001;322:1330-3. Tully 2002 Tully L, Gates S, Brocklehurst P, McKenzie-McHarg K, Ayers S. Surgical techniques used during caesarean section operations: results of a national survey of practice in the UK. European Journal of Obstetrics & Gynecology and Reproductive Biology 2002;102(2):120-6.
Volmink 2007 Volmink J, Siegfried NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. In: Cochrane Database of Systematic Reviews, 1, 2007. 10.1002/14651858.CD003510.pub2. Wallace 1980 Wallace D, Hernandez W, Schlaerth JB, Nalick RN, Morrow CP. Prevention of abdominal wound disruption utilizing the Smead-Jones closure technique. Obstetrics & Gynecology 1980;56:226-30. Wallin 1999 Wallin G, Fall O. Modied Joel-Cohen technique for caesarean delivery. British Journal of Obstetrics and Gynaecology 1999;106:221-6. Wilkinson 2006a Wilkinson C, Enkin MW. Lateral tilt for caesarean section. In: Cochrane Database of Systematic Reviews, 3, 2006. 10.1002/14651858.CD000120.pub2. Wilkinson 2006b Wilkinson C, Enkin MW. Absorbable staples for uterine incision at caesarean section. In: Cochrane Database of Systematic Reviews, 3, 2006. 10.1002/14651858.CD000005.pub2. Wilkinson 2006c Wilkinson C, Enkin MW. Manual removal of placenta at caesarean section. In: Cochrane Database of Systematic Reviews, 3, 2006. 10.1002/14651858.CD000130.pub2. Wood 1999 Wood RM, Simon H, Oz AU. Pelosi-type vs. traditional cesarean delivery. A prospective comparison. Journal of Reproductive Medicine 1999;44:788-95. * El asterisco seala los documentos ms importantes para este estudio
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TABLAS Characteristics of included studies Study Methods Participants Bjorklund 2000 Computer-randomised sequence in sealed opaque envelopes. Assessment could not be blinded. Women undergoing elective or emergency CS with general anesthesia at > 37 gestational weeks. Exclusion criteria: repeat CS, previous abdominal surgery, pyrexia > 39C, severe anemia, bleeding disorders, uterine rupture, previous postpartum haemorrhage. Misgav-Ladach technique (n = 169) vs traditional CS (n = 170): lower midline abdominal incision, double-layer closure of the uterus, closure of both peritoneal layers. Operating time, blood loss, blood loss exceeding 500 ml, suture material used, Apgar scores at 5 and 10 minutes, intraoperative antibiotics, postoperative complication, length of hospital stay. Muhimbili medical centre, Dar es Salaam, Tanzania. 20.12.1996-08.03.1997. 16 surgeons. There was uncertainty about 4 possible losses to follow up. 1 women in each group received the non-allocated technique. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: B. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. A - Adequate Dani 1998 Randomisation not described. Assessment of outcome blind. Infants delivered at > 36 gestational weeks admitted to nursery or intensive care. Excluded - major congenital abnormalities, 9 - incomplete data. 76 (53%) delivered by Stark modified CS and 68 (47%) by traditional CS. Respiratory depression, perinatal asphyxia, frequency and duration of hospital admission. Hospital of Rovigo, Italy. January to December 1996. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: B. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: A. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: B. 8. analysis of participants in randomised groups: A. B - Unclear
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Interventions Outcomes
Notes
Allocation concealment Study Methods Participants Interventions Outcomes Notes
Allocation concealment
Characteristics of included studies Study Methods Participants Interventions Outcomes Notes Darj 1999 Randomly allocated, used sealed opaque envelopes opened by women's husband before the surgery. Assessment not blind. Women undergoing first CS. Exclusion - previous abdominal surgery. Misgav-Ladach (n = 25) vs Pfannenstiel (n = 25). Duration of operation, blood loss, analgesic injections, duration and doses, tiome to drinking water and to standing up, first bowel action, days in hospital. University Hospital Uppsala, Sweden. 1996-1997. 1 surgeon. No prophylactic antibiotics used. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: A. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: C. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. A - Adequate Ferrari 2001 Randomisation by sealed opaque envelopes stored by each of 10 surgeons. Women requiring first CS, > 30 gestational weeks, eligible for CS by Pfannenstiel technique. Joel-Cohen (n = 83) vs Pfannenstiel (n = 75). Day of Urinary catheter removal, stopping intravenous fluids, liquid intake, food intake, flatus, and mobilization; fever, pain on day 1 and 2. San Raffaele Hospital and San Paolo Hospital of Milan School of Medicine, Italy. January 1997-June 1998. 10 senior surgeons. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: A. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: C. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. A - Adequate Franchi 1998b Randomisation computer-generated list of numbers. These assignments were placed in sequentially numbered sealed envelopes opened immediately before the start of operation.
Allocation concealment Study Methods
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Characteristics of included studies Participants Excluded - women with multiple pregnancy, 2 or more previous CS, previous longitudinal laparotomy, previous myomectomy, gestational age more than 30 weeks, antibiotics within 2 weeks prior to CS, requiring additional surgery. Joel-Cohen (n = 149) vs Pfannenstiel (n = 153). Operative time, opening time, bladder injury, intraoperative transfusion, postoperative hospital stay, change in haemoglobin concentration, postoperative ileus, wound infection, postoperative morbidity. Insubria University, Varese, Italy. April 1995-August 1997. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: A. 4. blinding of caregivers: B. 5. blinding of outcome assessment: B. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. A - Adequate Franchi 2002 Randomisation computer-generated, midwife opened sealed envelopes immediately before skin incision. Excluded - multiple pregnancy, 2 or more previous CS, maternal disease, previous CS before 32 gestational weeks, myomectomy, previous longitudinal abdominal incision. Joel-Cohen (n = 154) vs Pfannenstiel (n = 158). Operating time, extraction time, additional uterine stitches, additional haemostatic uterine stitches, intraoperative transfusion, bladder injury, change in haemoglobin concentration, time to passage of flatus, wound infection, postoperative morbidity, hospital stay. Insubria University, Varese, Italy. January 1998-May 2000. Junior surgeons. 2 women excluded in Joel-Cohen group - they required caesarean hysterectomy. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: A. 4. blinding of caregivers: B. 5. blinding of outcome assessment: B. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: B. 8. analysis of participants in randomised groups: A. A - Adequate Heimann 2000 Randomisation not described. Women with high-risk pregnancies. Groups didn't differ in age, gestational age, previous CS. Misgav-Ladach groups had more nulliparous women.
Notes
Allocation concealment Study Methods Participants Interventions Outcomes
Notes
Allocation concealment Study Methods Participants
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Characteristics of included studies Interventions Outcomes Modified Misgav-Ladach (skin incision as low as Pfannenstiel, n = 117) vs Pfannenstiel (n = 123). Duration of operation, Apgar score, cord blood pH, intraoperative complications, postoperative complications, fall in haemoglobin, haematoma formation, pyrexia, wound complications, hospital stay. Wiesban, Germany. 24.11.1998-25.05.1999. 3 women from Misgav-Ladach group were transferred into Pfannenstiel group - 1 due to obesity, 1 due to scaring from previous CS, 1 due to tumour which required removal. Analysis by intention to treat. Quality assessment: 1. generation of random allocation sequence: B. 2. allocation concealment: B. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: C. 6. compliance with allocated intervention: B. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. B - Unclear Koettnitz 1999 Randomisation alternative. Women requiring CS. Modified Cohen with low skin incision (n = 44) vs Pfannenstiel (n = 42). Wound infection, mobilisation, antibiotic use, operating time, cost of materials. Frauenklinik, Duisburg, Germany January 1996-July 1996. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: C. 3. blinding of participants: C. 4. blinding of caregivers: C. 5. blinding of outcome assessment: C. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. C - Inadequate Li 2001 Randomisation not described. Women requiring CS. Modified Misgav-Ladach (transversely incising fascia 2-3 cm, then dividing bluntly without opening and dissociating the visceral peritoneum, 2 layers suturing of low transverse uterine incision, closing the skin by continuous suturing, n = 59) vs Misgav-Ladach (n = 57) vs Pfannenstiel (n = 56). Operating time, delivery time, blood loss, postoperative pain, diet, bowel movement, and hospital stay.
Notes
Allocation concealment Study Methods Participants Interventions
Outcomes
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Characteristics of included studies Notes Xiehe Hospital, Tonojii. May-December 1999. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: C. 3. blinding of participants: D. 4. blinding of caregivers: D. 5. blinding of outcome assessment: D. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. C - Inadequate Mathai 2002 Randomisation in blocks, slips of paper with the allocated incision were placed in identical, consecutively-numbered sealed opaque envelopes Blood loss and time for surgery assessed by anaesthetist; postoperative analgesia on demand; allocation not known to anaesthetist or staff in postoperative ward. Women with singleton pregnancy, longitudinal lie, at term requiring CS under spinal anesthesia. Excluded: multiple pregnancy, previous abdominal surgery, need for midline or paramedian incision, spinal anesthesia contraindicated. Joel-Cohen (n = 51) vs Pfannenstiel (n = 50). Time to analgesia, delivery time, operative time, blood loss, time to oral fluids, total dose of analgesics, febrile morbidity, postoperative haematocrit, time to breastfeeding, time in special care nursery, hospital stay. Christian Medical College and Hospital, Vellore, India. 1 of 31 registrars performed the surgery. 4 women excluded from analysis: in Joel-Cohen group - 1 had caesarean hysterectomy, 1 had vaginal delivery prior to CS, 1 had ineffective spinal block; in Pfannenstiel group - 1 woman had ineffective spinal block. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: D. 4. blinding of caregivers: D. 5. blinding of outcome assessment: D. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: B. 8. analysis of participants in randomised groups: A. A - Adequate Mokgokong 1974 Randomisation using odd and even numbers of admission number. Women requiring CS who had intrauterine infection. 412 black and Indian women. Extraperitoneal (n = 239) vs intraperitoneal (n = 173) CS. Time to delivery, peritonitis, pelvic abscess, abdominal wound sepsis, secondary postpartum haemorrhage, further surgery, septicaemic shock, hospital stay, mortality.
Participants
Notes
Allocation concealment Study Methods Participants Interventions Outcomes
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Characteristics of included studies Notes Kind Edward VIII Hospital, Durban, SA. Quality assessment: 1. generation of random allocation sequence: B. 2. allocation concealment: C. 3. blinding of participants: D. 4. blinding of caregivers: D. 5. blinding of outcome assessment: D. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: B. 8. analysis of participants in randomised groups: A. C - Inadequate Moreira 2002 Randomisation was not described. Women requiring CS. Misgav-Ladach (n = 200) vs traditional (n = 200). Time to delivery, operative time, use of suture material, dose of analgesia, postoperative complications, hospital stay, cost. Dakar Teaching Hospital, Senegal. April-July 2000. Quality assessment: 1. generation of random allocation sequence: C. 2. allocation concealment: B. 3. blinding of participants: D. 4. blinding of caregivers: D. 5. blinding of outcome assessment: D. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. B - Unclear Wallin 1999b Randomisation - computer-generated in large blocks, using sealed envelopes opened by physicians just before surgery. Results of randomisation were known only to a single obstetrician who performed surgery. Outcome assessment was blind Women requiring elective CS with no history of abdominal surgery. Modified Joel-Cohen (3 cm higher than original Pfannenstiel, n = 36) vs Pfannenstiel (skin incision 3 cm higher than originally described, n = 36). Operating time, blood loss, intravenous fluids, blood effusion, haemoglobin, C-reactive protein, hospital stay.
Participants Interventions Outcomes
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Characteristics of included studies Notes Sahlgrenska University Hospital, Gothenburg, Sweden. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: B. 4. blinding of caregivers: B. 5. blinding of outcome assessment: B. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: A. 8. analysis of participants in randomised groups: A. A - Adequate Xavier 2005 Randomisation - outcome assessment blinded. Women for CS by 1 of 3 surgeons. Modified Misgav-Ladach (n = 88) vs Pfannenstiel-Kerr (n = 74). Operating time, requested paracetamol, bowel recovery, febrile morbidity, postoperative antibiotics, endometritis, wound complications. Porto University Hospital de Sao Joao, Portugal. 3 surgeons. Quality assessment: 1. generation of random allocation sequence: A. 2. allocation concealment: A. 3. blinding of participants: D. 4. blinding of caregivers: D. 5. blinding of outcome assessment: D. 6. compliance with allocated intervention: A. 7. completeness of follow-up data: B. 8. analysis of participants in randomised groups: A. A - Adequate
Allocation concealment
Notas: CS: caesarean sectionvs: versus
Characteristics of excluded studies Study Ansaloni 2001 Gaucherand 2001 Redlich 2001 Wallace 2000 Reason for exclusion Randomisation by alternative allocation. Not blinded. Randomisation using odd and even numbers of the date of surgery. Randomised by the first letter of surname, unequal groups 105 in Misgav-Ladach versus 67 in traditional group. Randomisation depended on availability of 1 of 3 surgeons. Women were randomised and then transferred between groups depending on the surgeons' availability. Intraperitoneal versus extraperitoneal caesarean section.
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TAB LAS ADICIONALES Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques Review Preoperative hair removal to reduce surgical site infection. Tanner J, Woodlings D, Moncaster K. 11 RCTs. 2 studies, 411 participants compared the Joel-Cohen incision with the Pfannenstiel incision. Main results No statistically significant difference in surgical site infections (SSI) was found comparing hair removal using either depilatory cream or razors with no hair removal (3 trials, 625 people). There were significantly more SSIs when people were shaved compared with either clipping (3 trials, 3193 people; RR 2.02, 95%.CI 1.21 to 3.36) or hair removal using a depilatory cream (7 trials, 1213 people; RR 1.54, 95%CI 1.05 to 2.24). No difference in SSIs was found between shaving (1 trial) or clipping (1 trial) on the day of surgery compared with the day before surgery. Practice There is no evidence that hair removal prior to surgery reduced SSI. If it is necessary to remove hair then both clipping and depilatory creams results in fewer SSIs than shaving using a razor. There is no difference in SSIs when patients are shaved or clipped one day before surgery or on the day of surgery. Research No trials were found that compared clipping with a depilatory cream. No trials were identified which compared clipping with no hair removal. No trials were found that compared depilatory cream at different times or that compared hair removal in different settings.
Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Webster J, Osborne S. 6 trials, 10,007 participants.
The antiseptic used in all trials was 4% chlorhexidine gluconate. In 3 trials involving 7691 participants bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs, (RR = 0.91 (95% CI 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95% CI 0.82 to 1.10). 3 trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). 2 trials of 1092 patients compared bathing with chlorhexidine with no washing, 1 large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95% CI 0.17 to 0.79). The second smaller study found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively. 2 trials were found which addressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections. 14 trials of double gloving (wearing 2 pairs of surgical latex gloves) were pooled and showed that there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). 8 trials of indicator gloves (coloured latex gloves worn underneath latex gloves to more rapidly alert the team to perforations) showed
This review provides no More research is clear evidence of benefit needed in this area. for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection.
Double gloving to reduce surgical cross-infection. Tanner J, Parkinson H. 2 trials on surgical site infections. 31 RCTs on glove perforations.
There is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, however the review has insufficient power for this outcome. The addition of a second pair of surgical gloves, triple gloving, knitted outer gloves and glove liners all significantly reduce
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Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17). 2 trials of glove liners (a glove knitted with cloth or polymers worn between 2 pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), 3 trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and 1 trial of triple gloving (3 pairs of latex surgical gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the innermost glove of a standard double glove in all comparisons. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Lipp A, Edwards P. 2 RCTs, 1453 participants. In 1 small trial there was a trend towards masks being associated with fewer infections, whereas in 1 large trial there was no statistically significant difference in infection rates between the masked and unmasked group. perforations to the innermost glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery.
From the limited results it Further research is is unclear whether wearing required. surgical face masks results in any harm or benefit to the patient undergoing clean surgery. From the limited results it is unclear whether wearing surgical face masks results in any harm or benefit to the patient undergoing clean surgery. The reduction of endometritis by two thirds to three quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective caesarean section.
Antibiotic prophylaxis for cesarean section. F Smaill, GJ Hofmeyr. 81 trials.
Use of prophylactic antibiotics in women undergoing caesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after caesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups: RR for endometritis for elective caesarean section (number of women = 2037) was 0.38 (95% CI 0.22 to 0.64); the RR for non-elective caesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective caesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective caesarean section (n = 2780) RR 0.36, 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43).
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Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques Antibiotic prophylaxis regimens and drugs for cesarean section. L Hopkins, F Smaill. 51 trials. The following results refer to reductions in the incidence of endometritis. Both ampicillin and first-generation cephalosporins have similar efficacy with an odds ratio (OR) of 1.27 (95% CI: 0.84 to 1.93). In comparing ampicillin with second or third-generation cephalosporins the OR was 0.83 (95% CI 0.54 to 1.26) and in comparing a first-generation cephalosporin with a second or third-generation agent the OR was 1.21 (95% CI 0.97-1.51). A multiple dose regimen for prophylaxis appears to offer no added benefit over a single dose regimen; OR 0.92 (95% CI 0.70 to 1.23). Systemic and lavage routes of administration appear to have no difference in effect; OR 1.19 (95% CI 0.81 to 1.73). Women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit (WMD 1.70, 95% CI 0.47 to 2.93, 1 trial, 231 women) and (WMD 3.10, 95% CI 1.73 to 4.47, 1 trial, 209 women). Compared to GA, women having either an epidural anaesthesia or spinal had a lower estimated maternal blood loss (WMD - 126.98 millilitres, 95% CI -225.06 to -28.90, 2 trials, 256 women) and (WMD -84.79 millilitres, 95% CI -126.96 to -42.63, 2 trials, 279 women). More women preferred to have GA for subsequent procedures when compared with epidural (OR 0.56, 95% CI 0.32 to 0.96, 1 trial, 223 women) or spinal (OR 0.44, 95% CI 0.24 to 0.81, 221 women). The incidence of nausea was also less for this group of women compared with epidural (OR 3.17, 95% CI 1.64 to 6.14, 3 trials, 286 women) or spinal (OR 23.22, 95% CI 8.69 to 62.03, 209 women). No significant difference was seen in terms of neonatal Apgar scores of 6 or less and of 4 or less at 1 and 5 minutes and need for neonatal resuscitation with oxygen. No difference was found between spinal and epidural techniques with regards to failure rate (RR 0.98, 95% CI 0.23 to 4.24; 4 studies), need for additional intraoperative analgesia (RR 0.88, 95% CI 0.59 to 1.32; 5 studies), need for conversion to general anaesthesia intraoperatively, maternal satisfaction, need for postoperative pain relief and neonatal intervention. Women receiving spinal anaesthesia for caesarean section
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Both ampicillin and first generation cephalosporins have similar efficacy in reducing postoperative endometritis. There does not appear to be added benefit in utilizing a more broad spectrum agent or a multiple dose regimen.
There is a need for an appropriately designed randomised trial to test the optimal timing of administration (immediately after the cord is clamped versus preoperative).
Regional versus general anaesthesia for caesarean section. BB Afolabi, FEA Lesi, NA Merah. 16 trials, 1586 women.
There is not enough evidence from this review to show that either regional or general anaesthesia is superior to the other in terms of major maternal or neonatal outcomes. Thus, the choice of one over the other lies with other criteria such as estimated blood loss which appears to be reduced with the use of regional anaesthesia, and client satisfaction and nausea and vomiting which appear to be reduced with general anaesthesia.
Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.
Spinal versus epidural anaesthesia for caesarean section. K Ng, J Parsons, AM Cyna, P Middleton. 10 trials, 751 women.
Both spinal and epidural techniques are shown to provide effective anaesthesia for caesarean section. Both techniques are associated with moderate degrees of maternal satisfaction. Spinal anaesthesia has a shorter onset time, but
More research is needed on intraoperative side-effects and postoperative complications of spinal and epidural anaesthesia.
Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques showed reduced time from start of the anaesthetic to start of the operation (WMD 7.91 minutes less (95% CI -11.59 to -4.23; 4 studies), but increased need for treatment of hypotension RR 1.23 (95% CI 1.00 to 1.51; 6 studies). treatment for hypotension is more likely if spinal anaesthesia is used. No conclusions can be drawn about intraoperative side-effects and postoperative complications because they were of low incidence or not reported, or both. Opinions of women and caregivers, severe immediate morbidity or long-term morbidity and mortality among mothers and infants were not evaluated. There is a also need to study if these procedures can be done safely under local anaesthesia in settings where safe general or regional anaesthesia is not available.
Abdominal surgical incisions for caesarean section. M Mathai, GJ Hofmeyr. 2 studies, 411 participants compared the Joel-Cohen incision with the Pfannenstiel incision.
65% reduction in reported postoperative The Joel-Cohen incision morbidity with the Joel-Cohen incision. 1 of has clinical and cost-saving the trials reported reduced postoperative benefits. analgesic requirements; operating time; delivery time; total dose of analgesia in the first 24 hours; estimated blood loss; postoperative hospital stay for the mother; and increased time to the first dose of analgesia compared to the Pfannenstiel group. No other significant differences were found in either trial. 2 studies compared muscle cutting incisions with Pfannenstiel incision. 1 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; need for blood transfusion; wound infection; physical tests on muscle strength at 3 months postoperative and postoperative hospital stay.
Tocolysis for Maternal and infant health outcomes were assisting delivery at not reported. caesarean section. JM Dodd, K Reid. 1 RCT, 97 women.
There is currently Research is needed insufficient information in this area. available from randomised trials to support or refute the routine or selective use of tocolytic agents to facilitate infant birth at the time of caesarean section. Leaving the peritoneum unsutured is not likely to be hazardous in the short term and may in fact, be of benefit. The long-term implications are not certain. Further research on the long-term benefits or complications of non-closure of the peritoneum at caesarean section is needed.
Closure versus non-closure of the peritoneum at caesarean section. AA Bamigboye, GJ Hofmeyr. Interventions comparison of leaving the visceral or parietal peritoneum, or both,
Non-closure of the peritoneum reduced operating time whether both or either layer was not sutured. For both layers, the operating time was reduced by 6.05 minutes. There was significantly less postoperative fever and reduced postoperative stay in hospital and reduced number of postoperative analgesic doses for visceral peritoneum and for both layer non-closure.
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Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques unsutured at caesarean section with a technique which involves suturing the peritoneum. 14 trials, 2908 women. Techniques and materials for closure of the abdominal wall in caesarean section. ER Anderson, S Gates. The risk of haematoma or seroma was reduced with fat closure compared with non-closure (RR) 0.52, 95% CI 0.33 to 0.82), as was the risk of 'wound complication' (RR 0.68, 95% CI 0.52 to 0.88). No difference in the risk of wound infection alone or other short-term outcomes was found. No long-term outcomes were reported. There was no difference in the risk of wound infection between blunt needles and sharp needles in 1 small study. No studies were found examining suture techniques or materials for closure of the rectus sheath or subcutaneous fat. Closure of the subcutaneous fat may reduce wound complications but it is unclear to what extent these differences affect the wellbeing and satisfaction of the women concerned. Further trials are justified to investigate whether the apparent increased risk of haematoma or seroma with non-closure of the subcutaneous fat is real. These should use a broader range of short- and long-term outcomes, and ensure that they are adequately powered to detect clinically important differences. Further research comparing blunt and sharp needles is justified, as are trials evaluating suturing materials and suturing techniques for the rectus sheath. Future studies should concentrate on minimizing scarring and infection and long-term maternal morbidity and scar appearance as well as an ability of scar to withstand rupture in future pregnancies.
Techniques and materials for skin closure in caesarean section. F Alderdice, D McKenna, J Dornan. Interventions comparison of the effects of skin closure techniques and materials on maternal outcomes and time taken to perform a caesarean section. 1 RCT, 66 women.
While operating time was significantly shorter when using staples, the use of absorbable subcuticular suture resulted in less postoperative pain and yielded a better cosmetic result at the postoperative visit.
There is currently no conclusive evidence about how the skin should be closed after caesarean section. The choice of technique and materials should be made by women in consultation with their obstetrician based on the limited information currently available.
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Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques Techniques for caesarean section. GJ Hofmeyr, M Mathai, A Shah, N Novikova. Comparison of the effects of complete methods of caesarean section not covered in the reviews of individual aspects of caesarean section technique. To summarise the findings of reviews of individual aspects of caesarean section technique. 14 studies, 2929 women. Shorter operating time, time to mobilisation, postoperative hospital stay and less blood loss in Misgav-Ladach group in comparison to traditional (lower midline) CS. Comparison of Misgav-Ladach and Pfannenstiel techniques for CS revealed advantages of the former technique in relation to such outcomes as time from skin incision to delivery of baby, blood loss, postoperative pain score, time to oral intake. Joel-Cohen CS technique was found to have advantages in comparison to Pfannenstiel technique, e.g. shorter operating time, less significant blood loss, shorter time to oral intake was shorter, shorter time from skin incision to delivery, shorter time to mobilization, less use of analgesia, shorter length of postoperative mothers hospital stay. 6 trials, which included 1026 women, significantly decreased number of cases of fever treated with antibiotics. The advantages of modified Misgav-Ladach technique over Pfannenstiel technique were seen in shorter operating time, shorter time from skin incision to delivery of baby, shorter time to oral intake, shorter time to return of bowel function, and less postoperative pain. The only advantage of modified Misgav-Ladach technique over Misgav-Ladach technique was shorter time from skin incision to delivery of baby. Extraperitoneal CS in women with severe intrauterine sepsis had less number of serious complications in comparison to intraperitoneal technique. Other outcomes that favoured extraperitoneal CS were the rate of fever treated with antibiotics. More women in a group, which had extraperitoneal CS, had repeat procedures on the wound in comparison to these who had intraperitoneal CS. No difference in the risk of wound infection, other wound complications, febrile morbidity or endometritis in women who had wound drains compared with those who did not. There was some evidence that caesarean sections may be about 5 minutes shorter and that blood loss may be slightly lower when drains were not used. Available evidence suggests that Misgav-Ladach, modified Misgav-Ladach and Joel-Cohen CS techniques have advantages over Pfannenstiel and traditional (lower midline) CS techniques in relation to short-term outcomes. There is no evidence in relation to long-term outcomes. Extraperitoneal CS has advantages over intraperitoneal CS in septic women in relation to serious maternal mortality and febrile morbidity. Further research of the long-term outcomes after different CS techniques is needed. The study of women and caregivers satisfaction with surgery as well as healthcare facilities use will be useful. None of the studies compared Joel-Cohen and Misgav-Ladach CS techniques.
Wound drainage for CS. Gates S, Anderson ER. 7 trials (1993 women).
There is no evidence in the 7 small trials included to suggest that the routine use of wound drains at CS confers any benefit on the women involved. These trials do not answer the question of whether wound drainage is of benefit when haemostasis is not felt to be adequate.
Further large trials are justified to examine the role of different types of wound drain at CS, comparing the use of drains in women with different degrees of obesity and in women having first or repeat CS and
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Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques intrapartum or prelabour CS, women's views and experience of drains. Tissue adhesives for closure of surgical incision. Couthard P, Worthington H, Esopsito M, van der Elst M, van Waes OJF. 8 RCT, 630 patients. No differences were found between various tissue adhesives and sutures (8 trials) for dehiscence, infection, satisfaction with cosmetic appearance when assessed by patients' or surgeons' general satisfaction. Nor were differences found between a tissue adhesive and tapes (2 trials) for infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. A statistically significant difference was found for surgeons' assessment of cosmetic appearance with mean difference 13 (95% CI 5 to 21), the higher mean rating for the tissue adhesive group. No RCTs that compared the wearing of finger rings with the removal of finger rings. No trials of nail polish wearing/removal that measured patient outcomes, including surgical infection. 1 small RCT, which evaluated the effect of nail polish on the number of bacterial colony forming units on the hands after preoperative hand washing (also called surgical scrubbing). Nurses were allocated to: unpolished nails, freshly applied nail polish (less than 2 days old), or old nail polish (more than 4 days old). Both before and after surgical scrubbing, there was no significant difference in the number of bacteria on the hands. There was significant heterogeneity in the comparisons and the results could not be pooled. In 1 study, infection rates were significantly lower when skin was prepared using chlorhexidine compared with iodine. There was no evidence of a benefit in 4 trials associated with the use of iodophor impregnated drapes. Early oral fluids or food were associated with: reduced time to first food intake (1 study, 118 women; the intervention was a slush diet and food was introduced according to clinical parameters; WMD - 7.20 hours, 95% CI -13.26 to -1.14); reduced time to return of bowel sounds (1 study, 118 women; -4.30 hours, -6.78 to -1.82); reduced postoperative
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Surgeons may consider the use of tissue adhesives as an alternative to sutures or adhesive tape for the closure of incisions in the operating room.
There is a need for trials in all areas but in particular to include patients that require incision closure in areas of high tension and patients of general health that may impair wound healing.
Removal of nail polish and finger rings to prevent surgical infection. Arrowsmith VA, Maunder JA, Sargent RJ, Taylor R.
Not enough evidence Trials in this area about whether people are required. working in operating theatres can wear nail polish or rings on their fingers without increasing patients' infection rates.
Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Edwards PS, Lipp A, Holmes A. 3 RCTs. Early compared with delayed oral fluids and food after caesarean section. L Mangesi, GJ Hofmeyr. 6 RCTs.
There is insufficient Further research is research examining the needed. effects of preoperative skin antiseptics to allow conclusions to be drawn regarding their effects on postoperative surgical wound infections. There was no evidence Further research is from the limited justified. randomised trials reviewed, to justify a policy of withholding oral fluids after uncomplicated CS.
Table 01 Summary of Cochrane reviews on various aspects of caesarean section techniques hospital stay following surgery under regional analgesia (2 studies, 220 women; - 0.75 days, -1.37 to -0.12 - random-effects model); and a trend to reduced abdominal distension (3 studies, 369 women; RR 0.78, 95% CI 0.55 to 1.11). No significant differences were identified with respect to nausea, vomiting, time to bowel action/passing flatus, paralytic ileus and number of analgesic doses. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. S Gates, P Brocklehurst, LJ Davis. 8 trials, 649 women. It was not possible to assess the effects of any of these interventions on most outcomes, especially rare outcomes such as death, thromboembolic disease and osteoporosis, because of small sample sizes and the small number of trials making the same comparisons. There is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period. Large scale randomised trials of currently-used interventions should be conducted.
Table 02 Routine caesarean section technique based on the best available evidence Procedure Preoperative hair removal. Best practice Evidence No difference in removal or not removal Preoperative hair removal to reduce surgical of hair, no difference in timing of removal site infection. (a day prior to surgery or on the day of Tanner J, Woodlings D, Moncaster K. surgery). If it is necessary to remove hair then both clipping and depilatory creams results in fewer surgical site infections than shaving using a razor. No benefit for preoperative showering or Preoperative bathing or showering with skin bathing with chlorhexidine over other wash antiseptics to prevent surgical site infection. products. Webster J, Osborne S. Some advantage in chlorhexidine use over Preoperative skin antiseptics for preventing iodine. surgical wound infections after clean surgery. Edwards PS, Lipp A, Holmes A. Ampicillin or first-generation Antibiotic prophylaxis for caesarean section. cephalosporins should be used to reduce F Smaill, GJ Hofmeyr; Antibiotic prophylaxis infectious morbidity. regimens and drugs for caesarean section. L Hopkins, F Smaill. Should be used to reduce perforation in innermost glove. Double gloving to reduce surgical cross-infection. Tanner J, Parkinson H.
Preoperative bathing or showering with skin antiseptics. Preoperative skin antiseptics. Antibiotic prophylaxis.
Double gloving.
Disposable surgical face Unclear harm or benefit of wearing masks. Disposable surgical face masks for preventing masks. surgical wound infection in clean surgery. Lipp A, Edwards P.
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Table 02 Routine caesarean section technique based on the best available evidence Anaesthesia. Not enough evidence on major complications. Regional anaesthesia associated with less blood loss and more discomfort than general anaesthesia. Spinal anaesthesia associated with quicker onset and more hypotension than epidural.. Not enough evidence. Regional versus general anaesthesia for caesarean section; BB Afolabi, FEA Lesi, NA Merah; Spinal versus epidural anaesthesia for caesarean section. K Ng, J Parsons, AM Cyna, P Middleton.
Lateral and/or head-down tilt.
Cochrane review in this area is pending.
Abdominal wall opening. Joel-Cohen or Misgav-Ladach techniques Abdominal surgical incisions for caesarean have advantages over Pfannenstiel and section. lower midline incisions. M Mathai, GJ Hofmeyr. Bladder peritoneum reflection. Uterine incision. Not enough evidence. Not enough evidence; transverse lower segment most widely used. Surgical techniques involving the uterus at the time of caesarean section. [Protocol, review pending]. JM Dodd, ER Anderson, S Gates.
Uterine opening.
Not enough evidence; options: by scalpel, Surgical techniques involving the uterus at the scissors, blunt dissection, or using time of caesarean section. absorbable staples. [Protocol, review pending]. JM Dodd, ER Anderson, S Gates. Cord traction associated with less blood loss and infection than manual removal. Cochrane review in press.
Placental removal.
Uterine exteriorisation for No significant differences between intra- Jacobs-Jokhan and Hofmeyr, Cochrane review. repair. and extraperitoneal repairs. Uterine closure. Not enough evidence. Surgical techniques involving the uterus at the time of caesarean section. [Protocol, review pending]. JM Dodd, ER Anderson, S Gates. Closure versus non-closure of the peritoneum at caesarean section. AA Bamigboye, GJ Hofmeyr.
Peritoneal closure.
Leave peritoneum opened.
Fascia closure.
No evidence on methods or materials for Techniques and materials for closure of the closure of fascia. abdominal wall in caesarean section. ER Anderson, S Gates.
Closure of subcutaneous Closure reduces wound haematoma and Techniques and materials for closure of the tissue. seroma. abdominal wall in caesarean section. ER Anderson, S Gates. Drainage of the peritoneal cavity. Drainage of subcutaneous layer. No evidence. No difference in outcomes when used routinely. Wound drainage for CS. Gates S, Anderson ER.
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Table 02 Routine caesarean section technique based on the best available evidence Skin closure. Subcuticular suture or interrupted suture Tissue adhesives for closure of surgical or staples or tissue adhesives depending incision. on preference. Couthard P, Worthington H, Esopsito M, van der Elst M, van Waes OJF. No evidence to justify withholding oral fluids after uncomplicated CS. Early compared with delayed oral fluids and food after caesarean section. L Mangesi, GJ Hofmeyr. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. S Gates, P Brocklehurst, LJ Davis.
Early compared with delayed oral fluids and food after caesarean section. Thromboprophylaxis.
No evidence.
CARTULA Titulo Autor(es) Contribucin de los autores Tcnicas para la cesrea Hofmeyr GJ, Mathai M, Shah A, Novikova N GJ Hofmeyr (GJH) desarroll el primer borrador del protocolo. M Mathai (MM) colabor con los posteriores borradores. N Novikova (NN) prepar el primer borrador de la revisin. GJH, MM, NN y A Shah colaboraron en la extraccin de datos y en la finalizacin de la revisin. GJH avala la revisin. 2004/1
Nmero de protocolo publicado inicialmente Nmero de revisin publicada inicialmente Fecha de la modificacin ms reciente" "Fecha de la modificacin SIGNIFICATIVA ms reciente Cambios ms recientes Fecha de bsqueda de nuevos estudios no localizados Fecha de localizacin de nuevos estudios an no incluidos/excluidos Fecha de localizacin de nuevos estudios incluidos/excluidos Fecha de modificacin de la seccin conclusiones de los autores
2008/1
La informacin no est disponible
06 noviembre 2007 El autor no facilit la informacin El autor no facilit la informacin
El autor no facilit la informacin
31 agosto 2007
El autor no facilit la informacin
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Direccin de contacto
Prof G Justus Hofmeyr Director/Hon. Professor, Effective Care Research Unit Department of Obstetrics and Gynaecology, East London Hospital Complex University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health Frere and Cecilia Makiwane Hospitals Private Bag X 9047 East London 5200 Eastern Cape SOUTH AFRICA Tlefono: +27 43 7092483 E-mail: gjh@global.co.za Facsimile: +27 43 7092483 CD004662 Cochrane Pregnancy and Childbirth Group HM-PREG
Nmero de la Cochrane Library Grupo editorial Cdigo del grupo editorial
RESUMEN DEL METANLISIS 01 Joel-Cohen based versus Pfannenstiel (all trials) Resultado 01 Serious complications 02 Blood loss 03 Blood transfusion 04 Operating time (minutes) 07 Postoperative haematocrit level 08 Haemoglobin fall > 4 g% 09 Wound infection 10 Wound haematoma 11 Wound breakdown 12 Endometritis No. of studies 4 5 3 5 1 1 6 1 3 3 No. of participants 913 481 681 481 101 240 1071 240 412 767 Statistical method Relative Risk (Fixed) 95% CI Effect size 1.31 [0.29, 5.91]
Weighted Mean Difference -64.45 [-91.34, -37.56] (Fixed) 95% CI Relative Risk (Fixed) 95% CI 4.08 [0.46, 36.40]
Weighted Mean Difference -18.65 [-24.84, -12.45] (Random) 95% CI Weighted Mean Difference 0.90 [-0.80, 2.60] (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Random) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI 0.42 [0.08, 2.13] 1.43 [0.52, 3.91] 1.80 [0.98, 3.31] 0.75 [0.33, 1.70] 0.34 [0.01, 8.17]
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01 Joel-Cohen based versus Pfannenstiel (all trials) 13 Time to mobilisation (hours) 14 Time to oral intake (hours) 15 Time to return of bowel function (hours) 16 Time to breastfeeding initiation (hours) 17 Fever treated with antibiotics or as defined by trial authors 18 Repeat operative procedures on the wound 19 Postoperative pain as measured by trial authors 20 Number of analgesic injections 24 Time from skin incision to delivery (minutes) 28 Apgar score < 7 at 5 minutes 29 Neonatal intensive care admission 37 Length of postoperative stay for mother (days) 2 5 3 1 8 2 2 2 5 1 1 4 208 481 222 101 1412 172 172 151 575 158 310 323 Weighted Mean Difference -2.86 [-11.29, 5.56] (Random) 95% CI Weighted Mean Difference -3.92 [-7.13, -0.71] (Random) 95% CI Weighted Mean Difference -6.72 [-15.26, 1.81] (Random) 95% CI Weighted Mean Difference -5.50 [-13.62, 2.62] (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI 0.47 [0.28, 0.81] 0.16 [0.02, 1.54]
Weighted Mean Difference -14.18 [-18.31, -10.04] (Fixed) 95% CI Weighted Mean Difference -0.92 [-1.20, -0.63] (Fixed) 95% CI Weighted Mean Difference -3.84 [-5.41, -2.27] (Random) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI 0.18 [0.01, 3.71] 1.19 [0.44, 3.20]
Weighted Mean Difference -0.99 [-1.44, -0.54] (Fixed) 95% CI
04 Joel-Cohen based versus traditional (lower midline incision) (all trials) Resultado 02 Blood loss 03 Blood transfusions 04 Operating time 08 Postoperative anaemia 09 Wound infection 11 Wound breakdown 12 Endometritis No. of studies 1 0 1 1 1 1 1 No. of participants 339 0 339 339 339 339 400 Statistical method Effect size
Weighted Mean Difference -93.00 [-132.72, (Fixed) 95% CI -53.28] Relative Risk (Fixed) 95% CI Not estimable
Weighted Mean Difference -7.30 [-8.32, -6.28] (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI 0.60 [0.22, 1.62] 1.14 [0.68, 1.91] 0.34 [0.04, 3.19] 2.50 [0.49, 12.74]
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04 Joel-Cohen based versus traditional (lower midline incision) (all trials) 13 Time to mobilistion 17 Fever treated with antibiotics or as defined by trialists 37 Length of postoperative hospital stay for mother 1 1 1 339 339 339 Weighted Mean Difference -16.06 [-18.22, -13.90] (Fixed) 95% CI Relative Risk (Fixed) 95% CI 1.38 [0.75, 2.54]
Weighted Mean Difference -0.82 [-1.08, -0.56] (Fixed) 95% CI
07 Misgav-Ladach versus modified Misgav-Ladach (all trials) Resultado 02 Blood loss 04 Operating time 14 Time to oral intake 15 Time to return of bowel function 19 Postoperative pain as measured by trial authors 24 Time from skin incision to delivery 37 Length of postoperative hospital stay for mother No. of studies 1 1 1 1 1 1 1 No. of participants 116 116 116 116 116 116 116 Statistical method Effect size
Weighted Mean Difference 14.00 [-0.70, 28.70] (Fixed) 95% CI Weighted Mean Difference -0.80 [-2.98, 1.38] (Fixed) 95% CI Weighted Mean Difference 1.40 [-1.28, 4.08] (Fixed) 95% CI Weighted Mean Difference 1.50 [-1.78, 4.78] (Fixed) 95% CI Weighted Mean Difference 2.30 [-0.97, 5.57] (Fixed) 95% CI Weighted Mean Difference 2.10 [1.10, 3.10] (Fixed) 95% CI Weighted Mean Difference 0.10 [-0.99, 1.19] (Fixed) 95% CI
10 Extraperitoneal versus intraperitoneal caesarean section Resultado 01 Serious complications 05 Maternal mortality 17 Fever treated with antibiotics or as defined by trialists 18 Repeat operative procedures on the wound No. of studies 1 1 1 1 No. of participants 412 412 412 412 Statistical method Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Effect size 0.12 [0.02, 0.88] 0.17 [0.02, 1.37] 0.42 [0.27, 0.65] 1.50 [0.70, 3.20]
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GRFICOS Y OTRAS TABLAS Fig. 01 Joel-Cohen based versus Pfannenstiel (all trials)
01.01 Serious complications
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01.02 Blood loss
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01.03 Blood transfusion
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01.04 Operating time (minutes)
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01.07 Postoperative haematocrit level
01.08 Haemoglobin fall > 4 g%
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01.09 Wound infection
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01.10 Wound haematoma
01.11 Wound breakdown
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01.12 Endometritis
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01.13 Time to mobilisation (hours)
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01.14 Time to oral intake (hours)
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01.15 Time to return of bowel function (hours)
01.16 Time to breastfeeding initiation (hours)
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01.17 Fever treated with antibiotics or as defined by trial authors
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01.18 Repeat operative procedures on the wound
01.19 Postoperative pain as measured by trial authors
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01.20 Number of analgesic injections
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01.24 Time from skin incision to delivery (minutes)
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01.28 Apgar score < 7 at 5 minutes
01.29 Neonatal intensive care admission
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01.37 Length of postoperative stay for mother (days)
Fig. 04 Joel-Cohen based versus traditional (lower midline incision) (all trials)
04.02 Blood loss
04.03 Blood transfusions El autor no facilit las grficos o las tablas
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04.04 Operating time
04.08 Postoperative anaemia
04.09 Wound infection
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04.11 Wound breakdown
04.12 Endometritis
04.13 Time to mobilistion
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04.17 Fever treated with antibiotics or as defined by trialists
04.37 Length of postoperative hospital stay for mother
Fig. 07 Misgav-Ladach versus modified Misgav-Ladach (all trials)

07.02 Blood loss
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07.04 Operating time
07.14 Time to oral intake
07.15 Time to return of bowel function
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07.19 Postoperative pain as measured by trial authors
07.24 Time from skin incision to delivery
07.37 Length of postoperative hospital stay for mother
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Fig. 10 Extraperitoneal versus intraperitoneal caesarean section

10.01 Serious complications
10.05 Maternal mortality
10.17 Fever treated with antibiotics or as defined by trialists
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10.18 Repeat operative procedures on the wound
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Tcnicas para la cesrea

Hofmeyr GJ, Mathai M, Shah A, Novikova N

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NHS Programme for Research and Development UK

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Allocation concealment Study Methods Participants Interventions Outcomes Notes

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Allocation concealment Study Methods Participants Interventions Outcomes Notes

Allocation concealment Study Methods

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Allocation concealment Study Methods Participants Interventions Outcomes

Allocation concealment Study Methods Participants

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Allocation concealment Study Methods Participants Interventions Outcomes Notes

Allocation concealment Study Methods Participants Interventions

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Allocation concealment Study Methods

Allocation concealment Study Methods Participants Interventions Outcomes

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Allocation concealment Study Methods Participants Interventions Outcomes Notes

Allocation concealment Study Methods

Participants Interventions Outcomes

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Allocation concealment Study Methods Participants Interventions Outcomes Notes

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Antibiotic prophylaxis for cesarean section. F Smaill, GJ Hofmeyr. 81 trials.

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Tcnicas para la cesrea

Lateral and/or head-down tilt.

Cochrane review in this area is pending.

Leave peritoneum opened.

Tcnicas para la cesrea

La informacin no est disponible

06 noviembre 2007 El autor no facilit la informacin El autor no facilit la informacin

El autor no facilit la informacin

El autor no facilit la informacin

Tcnicas para la cesrea

Nmero de la Cochrane Library Grupo editorial Cdigo del grupo editorial

Tcnicas para la cesrea

Weighted Mean Difference -0.99 [-1.44, -0.54] (Fixed) 95% CI

Tcnicas para la cesrea

Weighted Mean Difference -0.82 [-1.08, -0.56] (Fixed) 95% CI

Tcnicas para la cesrea