Extra‐abdominal versus intra‐abdominal repair of the uterine incision at caesarean section

Donna Jacobs‐Jokhan; G Justus Hofmeyr

doi:10.1002/14651858.CD000085.pub2

Reparación extraabdominal versus intraabdominal de la incisión uterina en la operación cesárea

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Referencias

References to studies included in this review

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Edi‐Osagie ECO, Hopkins RE, Ogbo V, Lockhat‐Clegg F, Ayeko M, Akpala WO, et al. Uterine exteriorisation at caesarean section: influence on maternal morbidity. British Journal of Obstetrics and Gynaecology 1998;105:1070‐8.

Hershey DW, Quilligan EJ. Extraabdominal uterine exteriorization at cesarean section. Obstetrics & Gynecology 1978;52:189‐92.

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Magann EF, Dodson MK, Allbert JR, McCurdy CM, Martin RW, Morrison JC. Blood loss at time of caesarean section by method of placental removal and exteriorisation versus in situ repair of the uterine incision. Surgery, Gynecology and Obstetrics 1993;177:389‐92.

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Magann EF, Dodson MK, Harris RL, Floyd RC, Martin JN, Morrison JC. Does method of placental removal or site of uterine incision repair alter endometritis after cesarean delivery ?. Infectious Diseases in Obstetrics and Gynaecology 1993;1:65‐70.

Magann EF, Washburne JF, Harris RL, Bass JD, Duff WP, Morrison JC. Infectious morbidity following Cesarean delivery by method of placental removal and site of uterine repair. American Journal of Obstetrics and Gynecology 1995;172(1 Pt 2):301.

Magann EF, Washburne JF, Harris RL, Bass JD, Duff WP, Morrison JC. Infectious morbidity, operative blood loss and length of the operative procedure after cesarean delivery by method of placental removal and site of uterine repair. Journal of the American College of Surgeons 1995;181:517‐20.

Magann EF, Dodson MK, Allbert JR, McCurdy CM, Martin RW, Morrison JC. Blood loss at time of cesarean section by method of placental removal and exteriorization vs in situ repair of the uterine incision. Surgery, Gynecology and Obstetrics 1993;177:389‐92.

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Magann EF, Dodson MK, Harris RL, Floyd RC, Martin JN, Morrison JC. Does method of placental removal or site of uterine incision repair alter endometritis after cesarean delivery ?. Infectious Diseases in Obstetrics and Gynaecology 1993;1:65‐70.

Magann EF, Washburne JF, Harris RL, Bass JD, Duff WP, Morrison JC. Infectious morbidity following Cesarean delivery by method of placental removal and site of uterine repair. American Journal of Obstetrics and Gynecology 1995;172(1 Pt 2):301.

Magann EF, Washburne JF, Harris RL, Bass JD, Duff WP, Morrison JC. Infectious morbidity, operative blood loss and length of the operative procedure after cesarean delivery by method of placental removal and site of uterine repair. Journal of the American College of Surgeons 1995;181:517‐20.

Wahab MA, Karantzis P, Eccersley PS, Russell IF, Thompson JW, Lindow SW. A randomised, controlled study of uterine exteriorisation and repair at caesarean section. British Journal of Obstetrics and Gynaecology 1999;106:913‐6.

References to studies excluded from this review

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Wallace RI, 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.

References to studies awaiting assessment

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The CORONIS Trial Collaborative Group. The CORONIS trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial. BMC Pregnancy and Childbirth 2007;7:24.

Coutinho IC, Ramos de Amorim MM, Katz L, Bandeira de Ferraz AA. Uterine exteriorization compared with in situ repair at cesarean delivery: a randomized controlled trial. Obstetrics & Gynecology 2008;111(3):639‐47.

Ding Y, Zhu F, Tao G. Clinical observation of improved passing peritoneum extraperitoneal cesarean sectron. Bulletin of Hunan Medical University 1997;22(5):434‐6.

Ezechi OC, Kalu BK, Njokanma FO, Nwokoro CA, Okeke GC. Uterine incision closure at caesarean section: a randomised comparative study of intraperitoneal closure and closure after temporary exteriorisation. West African Journal of Medicine 2005;24(1):41‐3.

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Magann EF, Dodson MK, Harris RL, Floyd RC, Martin JN, Morrison JC. Does method of placental removal or site of uterine incision repair alter endomyometritis after cesarean delivery?. American Journal of Obstetrics and Gynecology 1993;168:424.

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Orji EO, Olaleye AO, Loto OM, Ogunniyi SO. A randomised controlled trial of uterine exteriorisation and non‐exteriorisation at caesarean section. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008;48(6):570‐4.

Siddiqui M, Goldszmidt E, Tharmaratnam U, Kingdom J, Windrim J, Carvalho J. Complications of exteriorized versus in situ uterine repair at cesarean section under spinal anesthesia [abstract]. Anesthesiology 2005;102(Suppl 1):13.

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Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JC. Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial. Obstetrics & Gynecology 2007;110(3):570‐5.

Sood AK. Exteriorization of uterus at cesarean section. Journal of Obstetrics and Gynecology of India 2003;53(4):353‐8.

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Additional references

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Belizan J, Althabe F, Barros F, Alexander S. Rates and implication of cesarean sections in Latin America: ecological study. BMJ 1999;319:1397‐402.

Beukens P. Over‐medicalisation of maternal care in developing countries. In: Brouwere Van Lerberghe editor(s). Safe motherhood strategies: a review of the evidence. Antwerp: ITG Press, 2001:195‐206.

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Stock RJ, Skelton H. Fatal pulmonary embolism occurring two hours after exteriorisation of the uterus for repair, following caesarean section. Military Medicine 1985;150:549‐51.

Thomas J, Panjothy S. The National Sentinel Caesarean Section Audit Report. London: Royal College of Obstetricians and Gynaecologists, London, 2001.

References to other published versions of this review

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estudios excluidos
estudios a la espera de valoración
otras referencias

Wilkinson C, Enkin MW. Uterine exteriorization versus intraperitoneal repair at caesarean section. Cochrane Database of Systematic Reviews 1996, Issue 1. [DOI: 10.1002/14651858.CD000085]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Edi‐Osagie 1998

Methods	Randomised controlled trial. Randomisation by a table of random numbers, and allocations kept secure in sealed envelopes. Not stated whether or not these were opaque. Analysis by "intention to treat" principle.
Participants	194 women included. Exclusion of those with placenta previa, placental abruption, chorioamnionitis.
Interventions	2 groups ‐ uterine exteriorisation = 100 women. In situ repair = 94 women. All received prophylactic antibiotics. Pain relief by patient controlled analgesia ‐ morphine for the first 24‐36 hours, then rectal diclofenac/codeine‐ paracetamol combination PRN.
Outcomes	1. Hosp. stay. 2. Febrile morbidity. 3. UTI. 4. + HVS. 5. + wound swab. 6. Haemorrhage/blood transfusion. 7. Deep vein thrombosis. 8. Hematuria. 9. Pain and vomiting ‐ intra/postoperative. 10. Late puerperal pain. 11. Peri‐operative Hb change (Day 1 and Day 3 Hb). 12. Satisfaction with operation. 13. Failure of procedure. 14. Assessment of abdominal scar.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Hershey 1978

Methods	"all...were randomly assigned". No details of method of randomisation were given.
Participants	386 consecutive caesarean sections, in a county hospital. 78 (20%) excluded, as they required extensive surgical manipulations.
Interventions	2 groups ‐ 1. Experimental (159): eventration of uterus following delivery of fetus and placenta. 2. Control (149): repair of the uterus intraperitoneally. Subgroup formed within the 2 groups (1A and 2A), of those women with intact membranes at the time of operation. High morbidity subgroup identified (group Y), which contained patients with > 3 febrile days and / > 6 postoperative days in hospital.
Outcomes	1. Febrile days (excluding first 24 hours, when a temperature of 100.4 F or greater was recorded). 2. Postoperative infection. 3. Postoperative days in hospital. 4. Drop in haematocrit (patients with third trimester bleeding excluded from analysis). 5. Duration of operation. 6. Additional morbidity/wound infections 6‐8 weeks postoperatively.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Magann (M) 1993a

Methods	Randomised prospective study. Four groups of cards prepared from a random number table.
Participants	100 women having a caesarean section. Women with a bleeding diathesis, abnormal placentation, or prior postpartum haemorrhage were excluded.
Interventions	4 groups formed: Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of the uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. After delivery of the fetus, iv pitocin infused.
Outcomes	1. Blood loss (measured in suction apparatus, drapes, sponges and pads). 2. Postoperative haematocrit drop (Pre‐ and 48 hr. postoperative levels measured).
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Magann (M) 1993b

Methods	Random group assignment by card selection, from sealed opaque envelopes. Group appointment from random number table.
Participants	120 women undergoing caesarean section. Exclusion of women with chorioamnionitis, those who refused, those who received antenatal steroid/insulin therapy.
Interventions	4 groups formed: Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of the uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. No antibiotics received by any group of participants. Pelvis irrigated with normal saline prior to closure of abdominal wound in all cases.
Outcomes	1. Infectious morbidity (as gauged by: maternal temp > 38 C on 2 occasions, 6 hours apart, excluding the first 24 hours: uterine tenderness: foul smelling lochia: blood and urine cultures. 2. Duration of operation.
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Magann (M) 1995

Methods	Computer generated random sequence, sealed in opaque envelopes.
Participants	284 women undergoing caesarean section. Exclusion of women who refused, chorioamnionitis, history of previous caesarean section without labour.
Interventions	Participants divided into 4 equal groups (71). Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. All patients received prophylactic antibiotics.
Outcomes	1. Operative blood loss (measured in suction apparatus, surgical drapes and sponges). 2. Endometritis (temperature of 38 C on 2 occasions, 6 hours apart, excluding the first 24 hours; uterine tenderness: foul smelling lochia).
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Magann (S) 1993a

Methods	Randomised prospective study. Four groups of cards prepared from a random number table.
Participants	100 women having a caesarean section. Women with a bleeding diathesis, abnormal placentation, or prior postpartum haemorrhage were excluded.
Interventions	4 groups formed: Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of the uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. After delivery of the fetus, iv pitocin infused.
Outcomes	1. Blood loss (measured in suction apparatus, drapes, sponges and pads). 2. Postoperative haematocrit drop (Pre‐ and 48 hr postoperative levels measured).
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Magann (S) 1993b

Methods	Random group assignment by card selection, from sealed opaque envelopes. Group appointment from random number table.
Participants	120 women undergoing caesarean section. Exclusion of women with chorioamnionitis, those who refused, those who received antenatal steroid/insulin therapy.
Interventions	4 groups formed: Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of the uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. No antibiotics received by any group of participants. Pelvis irrigated with normal saline prior to closure of abdominal wound in all cases.
Outcomes	1. Infectious morbidity (as gauged by: maternal temp > 38 C on 2 occasions, 6 hours apart, excluding the first 24 hours: uterine tenderness: foul smelling lochia: blood and urine cultures. 2. Duration of operation.
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Magann (S) 1995

Methods	Computer generated random sequence, sealed in opaque envelopes.
Participants	284 women undergoing caesarean section. Exclusion of women who refused, chorioamnionitis, history of previous caesarean section without labour.
Interventions	Participants divided into 4 equal groups (71). Group 1 ‐ In situ repair, spontaneous placental removal. Group 2 ‐ Exteriorisation of uterus, spontaneous placental removal. Group 3 ‐ In situ repair, manual placental removal. Group 4 ‐ Exteriorisation of the uterus, manual placental removal. All patients received prophylactic antibiotics.
Outcomes	1. Operative blood loss (measured in suction apparatus, surgical drapes and sponges). 2. Endometritis (temperature of 38 C on 2 occasions, 6 hours apart, excluding the first 24 hours; uterine tenderness: foul smelling lochia).
Notes	Women recruited to the Magann studies were doubly randomised in trials with factorial design.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Wahab 1999

Methods	Randomised controlled trial. Randomisation by closed, numbered envelope technique, after anaesthetic technique established. Also, independent randomisation for 3 anaesthetic techniques used. Surgeons and anaesthetists blinded. Analysis by "intention to treat" principle.
Participants	316 women randomised, although only 288 included in analysis. (? 112 in pilot study, included in interim analysis.) Exclusion: Pre‐/postoperative blood specimens not taken, technical problems with anaesthetic, any change in standard operative procedure.
Interventions	1. Group 1 (139) Uterine exteriorisation. 2. Group 2 (149) Intra‐abdominal repair of the uterus.
Outcomes	1. Peri‐operative drop in Hb. 2. Duration of operation. 3. Duration of hospital stay/maternal morbidity. 4. Patient's perception of discomfort (intra‐operatively) 5. Nausea, vomiting and pain scores.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Hosp: hospital
hr: hour
HVS: high vaginal swab
IV: intravenous
temp: temperature
UTI: urinary tract infection

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Wallace 1984	We felt that the methods of uterine repair in this study compared extra‐peritoneal closure, rather than exteriorisation of the uterus, with intra‐peritoneal closure.

Data and analyses

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Comparison 1. Uterine exteriorization versus intraperitoneal repair at caesarean section

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operative blood loss (ml) Show forest plot	6	504	Mean Difference (IV, Fixed, 95% CI)	17.11 [‐23.15, 57.37]
Open in figure viewer Analysis 1.1 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 1 Operative blood loss (ml).
1.1 with manual removal of placenta	3	252	Mean Difference (IV, Fixed, 95% CI)	26.75 [‐34.54, 88.05]
1.2 with spontaneous separation of placenta	3	252	Mean Difference (IV, Fixed, 95% CI)	9.79 [‐43.59, 63.18]
1.3 placental management not stated	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Postoperative drop in haematocrit Show forest plot	3	324	Mean Difference (IV, Random, 95% CI)	‐0.47 [‐1.48, 0.54]
Open in figure viewer Analysis 1.2 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 2 Postoperative drop in haematocrit.
2.1 with manual removal of placenta	1	50	Mean Difference (IV, Random, 95% CI)	‐1.5 [‐3.52, 0.52]
2.2 with spontaneous separation of placenta	1	50	Mean Difference (IV, Random, 95% CI)	0.50 [‐0.47, 1.47]
2.3 placental management not stated	1	224	Mean Difference (IV, Random, 95% CI)	‐0.80 [‐0.90, ‐0.70]
3 Postoperative drop in haemoglobin levels (g/dl) Show forest plot	2	482	Mean Difference (IV, Random, 95% CI)	0.02 [‐0.62, 0.65]
Open in figure viewer Analysis 1.3 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 3 Postoperative drop in haemoglobin levels (g/dl).
4 Febrile morbidity for more than 3 days Show forest plot	1	308	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.17, 0.97]
Open in figure viewer Analysis 1.4 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 4 Febrile morbidity for more than 3 days.
5 Endometritis Show forest plot	3	592	Risk Ratio (M‐H, Random, 95% CI)	1.29 [0.64, 2.60]
Open in figure viewer Analysis 1.5 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 5 Endometritis.
6 Wound complications (infection, haematoma, breakdown) Show forest plot	3	735	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.53, 1.46]
Open in figure viewer Analysis 1.6 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 6 Wound complications (infection, haematoma, breakdown).
7 Nausea/vomiting (intra‐operative) Show forest plot	3	667	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.78, 1.80]
Open in figure viewer Analysis 1.7 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 7 Nausea/vomiting (intra‐operative).
8 Postoperative sepsis Show forest plot	1	308	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.19, 4.57]
Open in figure viewer Analysis 1.8 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 8 Postoperative sepsis.
9 Duration of operation Show forest plot	9	1281	Mean Difference (IV, Random, 95% CI)	0.82 [‐2.31, 3.95]
Open in figure viewer Analysis 1.9 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 9 Duration of operation.
10 Satisfaction with operation Show forest plot	1	139	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.82, 1.04]
Open in figure viewer Analysis 1.10 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 10 Satisfaction with operation.
11 Length of hospital stay (postoperative) Show forest plot	4	766	Mean Difference (IV, Fixed, 95% CI)	0.24 [0.08, 0.39]
Open in figure viewer Analysis 1.11 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 11 Length of hospital stay (postoperative).
12 Pain (intra‐operative) Show forest plot	2	360	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.79, 2.27]
Open in figure viewer Analysis 1.12 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 12 Pain (intra‐operative).
13 Failure of procedure Show forest plot	2	405	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.16, 1.28]
Open in figure viewer Analysis 1.13 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 13 Failure of procedure.
14 Patients requiring blood transfusion Show forest plot	2	482	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.43, 3.19]
Open in figure viewer Analysis 1.14 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 14 Patients requiring blood transfusion.
15 Deep vein thrombosis Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	2.82 [0.12, 68.42]
Open in figure viewer Analysis 1.15 Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 15 Deep vein thrombosis.

Analysis 1.1

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 1 Operative blood loss (ml).

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Analysis 1.2

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 2 Postoperative drop in haematocrit.

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Analysis 1.3

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 3 Postoperative drop in haemoglobin levels (g/dl).

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Analysis 1.4

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 4 Febrile morbidity for more than 3 days.

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Analysis 1.5

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 5 Endometritis.

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Analysis 1.6

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 6 Wound complications (infection, haematoma, breakdown).

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Analysis 1.7

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 7 Nausea/vomiting (intra‐operative).

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Analysis 1.8

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 8 Postoperative sepsis.

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Analysis 1.9

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 9 Duration of operation.

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Analysis 1.10

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 10 Satisfaction with operation.

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Analysis 1.11

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 11 Length of hospital stay (postoperative).

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Analysis 1.12

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 12 Pain (intra‐operative).

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Analysis 1.13

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 13 Failure of procedure.

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Analysis 1.14

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 14 Patients requiring blood transfusion.

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Analysis 1.15

Comparison 1 Uterine exteriorization versus intraperitoneal repair at caesarean section, Outcome 15 Deep vein thrombosis.

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Comparison 1. Uterine exteriorization versus intraperitoneal repair at caesarean section

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operative blood loss (ml) Show forest plot	6	504	Mean Difference (IV, Fixed, 95% CI)	17.11 [‐23.15, 57.37]

1.1 with manual removal of placenta	3	252	Mean Difference (IV, Fixed, 95% CI)	26.75 [‐34.54, 88.05]
1.2 with spontaneous separation of placenta	3	252	Mean Difference (IV, Fixed, 95% CI)	9.79 [‐43.59, 63.18]
1.3 placental management not stated	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Postoperative drop in haematocrit Show forest plot	3	324	Mean Difference (IV, Random, 95% CI)	‐0.47 [‐1.48, 0.54]

2.1 with manual removal of placenta	1	50	Mean Difference (IV, Random, 95% CI)	‐1.5 [‐3.52, 0.52]
2.2 with spontaneous separation of placenta	1	50	Mean Difference (IV, Random, 95% CI)	0.50 [‐0.47, 1.47]
2.3 placental management not stated	1	224	Mean Difference (IV, Random, 95% CI)	‐0.80 [‐0.90, ‐0.70]
3 Postoperative drop in haemoglobin levels (g/dl) Show forest plot	2	482	Mean Difference (IV, Random, 95% CI)	0.02 [‐0.62, 0.65]

4 Febrile morbidity for more than 3 days Show forest plot	1	308	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.17, 0.97]

5 Endometritis Show forest plot	3	592	Risk Ratio (M‐H, Random, 95% CI)	1.29 [0.64, 2.60]

6 Wound complications (infection, haematoma, breakdown) Show forest plot	3	735	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.53, 1.46]

7 Nausea/vomiting (intra‐operative) Show forest plot	3	667	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.78, 1.80]

8 Postoperative sepsis Show forest plot	1	308	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.19, 4.57]

9 Duration of operation Show forest plot	9	1281	Mean Difference (IV, Random, 95% CI)	0.82 [‐2.31, 3.95]

10 Satisfaction with operation Show forest plot	1	139	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.82, 1.04]

11 Length of hospital stay (postoperative) Show forest plot	4	766	Mean Difference (IV, Fixed, 95% CI)	0.24 [0.08, 0.39]

12 Pain (intra‐operative) Show forest plot	2	360	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.79, 2.27]

13 Failure of procedure Show forest plot	2	405	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.16, 1.28]

14 Patients requiring blood transfusion Show forest plot	2	482	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.43, 3.19]

15 Deep vein thrombosis Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	2.82 [0.12, 68.42]

Comparison 1. Uterine exteriorization versus intraperitoneal repair at caesarean section

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Referencias

References to studies included in this review

Edi‐Osagie 1998 {published data only}

Hershey 1978 {published data only}

Magann (M) 1993a {published data only}

Magann (M) 1993b {published data only}

Magann (M) 1995 {published data only}

Magann (S) 1993a {published data only}

Magann (S) 1993b {published data only}

Magann (S) 1995 {published data only}

Wahab 1999 {published data only}

References to studies excluded from this review

Wallace 1984 {published data only}

References to studies awaiting assessment

Coronis 2007 {published data only}

Coutinho 2008 {published data only}

Ding 1997 {published data only}

Ezechi 2005 {published data only}

Lager 2007 {published data only}

Magann 1993 {published data only}

Nafisi 2006 {published data only}

Nafisi 2007 {published data only}

Orji 2008 {published data only}

Siddiqui 2005 {published data only}

Siddiqui 2007 {published data only}

Sood 2003 {published data only}

Additional references

Belizan 1999

Beukens 2001

Cai 1998

Carrie 1990

Cosgrove 1958

Curtin 1997

Hofmeyr 2008

RevMan 2000 [Computer program]

Stock 1985

Thomas 2001

References to other published versions of this review

Wilkinson 1996

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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