Abdominal surgical incisions for caesarean section

Matthews Mathai; G Justus Hofmeyr; Namratha E Mathai

doi:10.1002/14651858.CD004453.pub3

Incisiones quirúrgicas abdominales para la operación cesárea

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Referencias

Referencias de los estudios incluidos en esta revisión

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Mathai M, Ambersheth S, George A. Comparison of two transverse abdominal incisions for cesarean delivery. International Journal of Gynecology & Obstetrics 2002;78:47‐9.

Referencias de los estudios excluidos de esta revisión

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Franchi M, Ghezzi F, Balestreri D, Miglierina M, Zanaboni F, Donadello N, et al. A randomized clinical trial of two surgical techniques for cesarean section. American Journal of Obstetrics and Gynecology 1998;178:S31.

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Referencias de los estudios en curso

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Juszczak E, Farrell B. The CORONIS Trial: international study of caesarean section surgical techniques. Trials 2011;112(Suppl 1):A103.

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

Referencias adicionales

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Referencias de otras versiones publicadas de esta revisión

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Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. [DOI: 10.1002/14651858.CD004453]

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Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews 2007, Issue 1. [DOI: 10.1002/14651858.CD004453.pub2]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Berthet 1989

Methods	Randomisation to Mouchel incision or Pfannenstiel incision. Method of randomisation unclear.
Participants	58 women undergoing caesarean section by Mouchel or Pfannenstiel incision. The study also included 61 women undergoing gynaecological surgery in Grenoble, France.
Interventions	Mouchel (muscle‐cutting) incision (n = 28) versus Pfannenstiel incision (n = 30).
Outcomes	Extraction time. Apgar scores. Umbilical cord pH.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Insufficient information.
Allocation concealment (selection bias)	Unclear risk	Insufficient information.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Insufficient information.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Potential risk of bias in assessment of extraction time and Apgar scores. intraoperative maternal variables studied. Cord pH estimated for all babies. Postoperative maternal assessment by single observer unaware of allocation.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Insufficient information.
Selective reporting (reporting bias)	Unclear risk	Insufficient information.
Other bias	Unclear risk	Insufficient information.

Franchi 2002

Methods	Multicentre study. Sealed envelopes containing computer‐generated random codes.
Participants	Women over 18 years, singleton pregnancy with indication for caesarean delivery in Varese, Italy and Berne, Switzerland. Exclusion criteria were: gestation less than 32 weeks, previous myomectomy, previous longitudinal abdominal incision, previous caesarean section prior to 32 weeks, 2 or more caesarean sections, maternal diseases requiring long‐term medical treatment. 2 women in Joel‐Cohen group were excluded after randomisation because they required caesarean hysterectomy.
Interventions	Joel‐Cohen incision (n = 154) versus Pfannenstiel incision (n = 158) for laparotomic access.
Outcomes	Extraction time defined as interval from skin incision to the clamping of the umbilical cord. Total operative time defined as the time from skin incision to the end of the skin closure. Postoperative morbidity defined when at least 1 of the following conditions occurred: wound infection grade 2‐5, endometritis, sepsis, requirement of blood transfusion, febrile morbidity, puerperal infection, urinary tract infection, and requirement of a re‐laparotomy. Neurodevelopmental assessment of infant at 6 months of age by single neonatologist.
Notes	Abdominal wound infection was graded with a 6‐grade score. Febrile morbidity was defined as temperature elevation to 38 deg C on 2 occasions 4 h apart, excluding the first 24 h and in the absence of known operative or non‐operative site infection. Puerperal endometritis was defined as postpartum temperature elevation to 38 deg C on 2 occasions 4 h apart with uterine tenderness, foul‐smelling lochia, and no other apparent sources of fever.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated randomisation.
Allocation concealment (selection bias)	Unclear risk	Envelopes used but unclear if sequentially numbered, opaque and sealed.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Since surgical team was aware of allocated intervention, assessment of intraoperative variables (secondary outcomes) may have been subject to bias.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Unclear if women and health workers providing postoperative newborn care and assessments were adequately blinded.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Data from 1 woman in each group excluded after randomisation because of caesarean hysterectomy.
Selective reporting (reporting bias)	Unclear risk	Insufficient information.
Other bias	Unclear risk	Insufficient information.

Giacalone 2002

Methods	Consecutively‐numbered, sealed envelopes containing allocation code.
Participants	Women (n = 120) more than 18 years old and at gestation more than 37 weeks undergoing elective or emergency caesarean delivery in Montpelier, France. Excluded were women with scarred abdominal wall, previous caesarean delivery, hernia, multifetal gestation, grand multiparity, diabetes mellitus, myopathy, corticosteroid therapy during pregnancy, on anticoagulants or having haemostatic disorder, having general anaesthesia. Mother was not asked to participate when neonate was at risk of transfer to neonatal unit. Postoperative questionnaires and outcome variables were available for 97 (87%). Postoperative isokinetic assessment was performed on 54 of these women only.
Interventions	Maylard (muscle‐cutting) incision (n = 43) versus Pfannenstiel incision (n = 54) for laparotomic access.
Outcomes	Intraoperative and postoperative morbidity. Immediate and late postoperative pain. Health‐related quality of life. Evaluation of abdominal wall function by physical therapist.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random number table used.
Allocation concealment (selection bias)	Low risk	Consequently numbered, sealed envelopes.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Since surgical team was aware of allocated intervention, assessment of intraoperative variables may have been subject to bias.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Women and health workers providing postoperative care and assessment were unaware of allocation.
Incomplete outcome data (attrition bias) All outcomes	High risk	Postoperative questionnaires and outcome variables available for only 81% of women with fewer women in intervention arm.
Selective reporting (reporting bias)	Unclear risk	Insufficient information.
Other bias	Unclear risk	Insufficient information.

Mathai 2002

Methods	Sealed, consecutively‐numbered envelopes containing randomisation code. Block randomisation to 1 of 2 interventions.
Participants	Women (n = 105) with singleton pregnancies at longitudinal lie at term requiring cesarean delivery under spinal anaesthesia in Vellore, India. Excluded were those with multiple pregnancy, any previous abdominal surgery, conditions where midline or paramedian incisions were planned, and where spinal anaesthesia was contraindicated. Spinal anaesthesia was ineffective in 1 in each group. 2 women in Joel Cohen group (1 underwent caesarean hysterectomy; 1 had vaginal delivery prior to caesarean section).
Interventions	Joel‐Cohen incision (n = 51) versus Pfannenstiel incision (n = 50) for laparotomic access.
Outcomes	Analgesia on demand within the first 4 h after surgery. Time between surgery and first dose of analgesic. Time between skin incision and delivery of infant. Time between skin incision and closure. Estimated blood loss. Time between surgery and intake of oral fluids. Total dose of analgesics in first 24 h. Febrile morbidity. Haematocrit ‐ preoperative and postoperative. Time from surgery to start of breastfeeding. Duration of stay in special care nursery. Duration of postoperative hospitalisation.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomisation.
Allocation concealment (selection bias)	Low risk	Sequentially numbered, opaque, sealed envelopes.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Since surgical team was aware of allocated intervention, assessment of intraoperative variables (secondary outcomes) may have been subject to bias.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Women and health workers providing postoperative care were not aware of allocation.
Incomplete outcome data (attrition bias) All outcomes	Low risk	4 exclusions after randomisation ‐ 1 in each group due to ineffective spinal analgesia; 1 in intervention group following caesarean hysterectomy for PPH; 1 in control group delivered vaginally before caesarean section.
Selective reporting (reporting bias)	Unclear risk	Insufficient information.
Other bias	Unclear risk	Insufficient information.

deg: degree
h: hour
PPH: postpartum haemorrhage

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Ansaloni 2001	Alternate allocation, not randomised.
Ayers 1987	Treatment allocation based on hospital number.
Ayres‐de‐Campos 2000	Not enough data provided in abstract for assessment.
Behrens 1997	Not enough data provided in abstract for assessment.
Bjorklund 2000	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Dani 1998	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Darj 1999	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Decavalas 1997	Not enough data provided in abstract for assessment.
Direnzo 2001	Not enough data provided in abstract for assessment.
Falls 1958	Not a randomised controlled trial.
Ferrari 2001	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Franchi 1998	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Gaucherand 2001	Treatment allocation by year of birth.
Hagen 1999	Not enough data provided in abstract for assessment.
Heimann 2000	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Hohlagschwandtner	Not a comparison of abdominal incisions.
Mahawerawat 2010	Not a comparison of abdominal incisions.
Meyer 1997	Not enough data provided in abstract for assessment.
Meyer 1998	Not enough data provided in abstract for assessment.
Moreira 2002	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Oguz 1998	Not a comparison of abdominal incisions
Redlich 2001	Treatment allocation by first letter of surname.
Wallin 1999	Comparison of abdominal incisions along with different combinations of other steps of surgery.
Xavier 1999	Not enough data provided in abstract for assessment.

Characteristics of ongoing studies [ordered by study ID]

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CORONIS 2007

Trial name or title	The Coronis Trial.
Methods	International multicentre study of caesarean section surgical techniques: a randomised fractional, factorial trial.
Participants	Women undergoing their first or second caesarean section through a transverse abdominal incision.
Interventions	Five comparisons using a 2 x 2 x 2 x 2 x 2 fractional factorial design: Blunt versus sharp abdominal entry. Exteriorisation of the uterus for repair versus intra‐abdominal repair. Single versus double layer closure of the uterus. Closure versus non‐closure of the peritoneum (pelvic and parietal). Chromic catgut versus Polyglactin‐910 for uterine repair.
Outcomes	Primary outcome: death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures; or blood transfusion.
Starting date	Not stated in reports.
Contact information	The CORONIS Trial Collaborative Group, Peter Brocklehurst: [email protected]
Notes

Data and analyses

Open in table viewer

Comparison 1. Joel‐Cohen versus Pfannenstiel incision

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postoperative febrile morbidity Show forest plot	2	411	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.14, 0.87]
Open in figure viewer Analysis 1.1 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 1 Postoperative febrile morbidity.
1.1 Joel‐Cohen versus Pfannenstiel incision	2	411	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.14, 0.87]
2 Postoperative analgesia on demand Show forest plot	1	101	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.40, 0.76]
Open in figure viewer Analysis 1.2 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 2 Postoperative analgesia on demand.
3 Time between surgery and first dose of analgesic (hours) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	0.80 [0.12, 1.48]
Open in figure viewer Analysis 1.3 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 3 Time between surgery and first dose of analgesic (hours).
4 Total dose of analgesics in 24 hours Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐0.89 [‐1.19, ‐0.59]
Open in figure viewer Analysis 1.4 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 4 Total dose of analgesics in 24 hours.
5 Number of analgesic injections required	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Duration of analgesics (hours)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of analgesic doses required	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Estimated blood loss (mL) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐58.0 [‐108.51, ‐7.49]
Open in figure viewer Analysis 1.8 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 8 Estimated blood loss (mL).
9 Change in pre‐ and postoperative haemoglobin levels (g)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Blood transfusion Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
Open in figure viewer Analysis 1.10 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 10 Blood transfusion.
11 Wound infection as defined by trial authors Show forest plot	1	310	Risk Ratio (M‐H, Random, 95% CI)	1.56 [0.45, 5.42]
Open in figure viewer Analysis 1.11 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 11 Wound infection as defined by trial authors.
12 Wound haematoma	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Postoperative pain absent on day 1	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Postoperative pain absent on day 2	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 "Significant" postoperative pain by visual analogue score	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Time (hours) from surgery to start of breastfeeding Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐5.5 [‐13.62, 2.62]
Open in figure viewer Analysis 1.16 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 16 Time (hours) from surgery to start of breastfeeding.
17 Total operative time (minutes) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐11.40 [‐16.55, ‐6.25]
Open in figure viewer Analysis 1.17 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 17 Total operative time (minutes).
18 Need for re‐laparotomy Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
Open in figure viewer Analysis 1.18 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 18 Need for re‐laparotomy.
19 Long‐term "significant" wound pain assessed by visual analogue score	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Not satisfied with wound	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Delivery time (minutes) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐1.90 [‐2.53, ‐1.27]
Open in figure viewer Analysis 1.21 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 21 Delivery time (minutes).
22 5‐minute Apgar score less than 7	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Admissions to special care baby unit ‐ all types Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.44, 3.20]
Open in figure viewer Analysis 1.23 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 23 Admissions to special care baby unit ‐ all types.
24 Admission to special care baby unit ‐ emergency caesarean section Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	1.45 [0.54, 3.86]
Open in figure viewer Analysis 1.24 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 24 Admission to special care baby unit ‐ emergency caesarean section.
25 Postoperative hospital stay for mother (days) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐1.5 [‐2.16, ‐0.84]
Open in figure viewer Analysis 1.25 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 25 Postoperative hospital stay for mother (days).
26 Stay in special care nursery (days) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐0.46 [‐0.95, 0.03]
Open in figure viewer Analysis 1.26 Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 26 Stay in special care nursery (days).

Open in table viewer

Comparison 2. Muscle‐cutting/Maylard versus Pfannenstiel incision

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postoperative febrile morbidity Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.08, 19.50]
Open in figure viewer Analysis 2.1 Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 1 Postoperative febrile morbidity.
2 Blood transfusion Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.02, 9.98]
Open in figure viewer Analysis 2.2 Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 2 Blood transfusion.
3 Wound infection as defined by trial authors Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.27, 5.91]
Open in figure viewer Analysis 2.3 Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 3 Wound infection as defined by trial authors.
4 Long‐term complication ‐ physical test at 3 months (Janda's test) Show forest plot	1	54	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.73, 0.93]
Open in figure viewer Analysis 2.4 Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 4 Long‐term complication ‐ physical test at 3 months (Janda's test).
5 Postoperative hospital stay for mother (days) Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	0.40 [‐0.34, 1.14]
Open in figure viewer Analysis 2.5 Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 5 Postoperative hospital stay for mother (days).

Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 1 Postoperative febrile morbidity.

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Analysis 1.2

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 2 Postoperative analgesia on demand.

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Analysis 1.3

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 3 Time between surgery and first dose of analgesic (hours).

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Analysis 1.4

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 4 Total dose of analgesics in 24 hours.

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Analysis 1.8

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 8 Estimated blood loss (mL).

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Analysis 1.10

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 10 Blood transfusion.

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Analysis 1.11

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 11 Wound infection as defined by trial authors.

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Analysis 1.16

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 16 Time (hours) from surgery to start of breastfeeding.

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Analysis 1.17

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 17 Total operative time (minutes).

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Analysis 1.18

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 18 Need for re‐laparotomy.

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Analysis 1.21

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 21 Delivery time (minutes).

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Analysis 1.23

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 23 Admissions to special care baby unit ‐ all types.

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Analysis 1.24

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 24 Admission to special care baby unit ‐ emergency caesarean section.

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Analysis 1.25

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 25 Postoperative hospital stay for mother (days).

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Analysis 1.26

Comparison 1 Joel‐Cohen versus Pfannenstiel incision, Outcome 26 Stay in special care nursery (days).

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Analysis 2.1

Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 1 Postoperative febrile morbidity.

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Analysis 2.2

Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 2 Blood transfusion.

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Analysis 2.3

Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 3 Wound infection as defined by trial authors.

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Analysis 2.4

Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 4 Long‐term complication ‐ physical test at 3 months (Janda's test).

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Analysis 2.5

Comparison 2 Muscle‐cutting/Maylard versus Pfannenstiel incision, Outcome 5 Postoperative hospital stay for mother (days).

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Comparison 1. Joel‐Cohen versus Pfannenstiel incision

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postoperative febrile morbidity Show forest plot	2	411	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.14, 0.87]

1.1 Joel‐Cohen versus Pfannenstiel incision	2	411	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.14, 0.87]
2 Postoperative analgesia on demand Show forest plot	1	101	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.40, 0.76]

3 Time between surgery and first dose of analgesic (hours) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	0.80 [0.12, 1.48]

4 Total dose of analgesics in 24 hours Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐0.89 [‐1.19, ‐0.59]

5 Number of analgesic injections required	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Duration of analgesics (hours)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Number of analgesic doses required	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Estimated blood loss (mL) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐58.0 [‐108.51, ‐7.49]

9 Change in pre‐ and postoperative haemoglobin levels (g)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Blood transfusion Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

11 Wound infection as defined by trial authors Show forest plot	1	310	Risk Ratio (M‐H, Random, 95% CI)	1.56 [0.45, 5.42]

12 Wound haematoma	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Postoperative pain absent on day 1	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Postoperative pain absent on day 2	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 "Significant" postoperative pain by visual analogue score	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Time (hours) from surgery to start of breastfeeding Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐5.5 [‐13.62, 2.62]

17 Total operative time (minutes) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐11.40 [‐16.55, ‐6.25]

18 Need for re‐laparotomy Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

19 Long‐term "significant" wound pain assessed by visual analogue score	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Not satisfied with wound	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Delivery time (minutes) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐1.90 [‐2.53, ‐1.27]

22 5‐minute Apgar score less than 7	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Admissions to special care baby unit ‐ all types Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.44, 3.20]

24 Admission to special care baby unit ‐ emergency caesarean section Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	1.45 [0.54, 3.86]

25 Postoperative hospital stay for mother (days) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐1.5 [‐2.16, ‐0.84]

26 Stay in special care nursery (days) Show forest plot	1	101	Mean Difference (IV, Fixed, 95% CI)	‐0.46 [‐0.95, 0.03]

Comparison 1. Joel‐Cohen versus Pfannenstiel incision

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Comparison 2. Muscle‐cutting/Maylard versus Pfannenstiel incision

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postoperative febrile morbidity Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.08, 19.50]

2 Blood transfusion Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.02, 9.98]

3 Wound infection as defined by trial authors Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.27, 5.91]

4 Long‐term complication ‐ physical test at 3 months (Janda's test) Show forest plot	1	54	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.73, 0.93]

5 Postoperative hospital stay for mother (days) Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	0.40 [‐0.34, 1.14]

Comparison 2. Muscle‐cutting/Maylard versus Pfannenstiel incision

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Referencias

Referencias de los estudios incluidos en esta revisión

Berthet 1989 {published and unpublished data}

Franchi 2002 {published data only (unpublished sought but not used)}

Giacalone 2002 {published data only (unpublished sought but not used)}

Mathai 2002 {published data only}

Referencias de los estudios excluidos de esta revisión

Ansaloni 2001 {published data only}

Ayers 1987 {published data only}

Ayres‐de‐Campos 2000 {published data only}

Behrens 1997 {published data only}

Bjorklund 2000 {published and unpublished data}

Dani 1998 {published and unpublished data}

Darj 1999 {published and unpublished data}

Decavalas 1997 {published data only}

Direnzo 2001 {published data only}

Falls 1958 {published data only}

Ferrari 2001 {published data only}

Franchi 1998 {published data only (unpublished sought but not used)}

Gaucherand 2001 {published data only}

Hagen 1999 {published data only}

Heimann 2000 {published data only (unpublished sought but not used)}

Hohlagschwandtner {published data only}

Mahawerawat 2010 {published data only}

Meyer 1997 {published data only}

Meyer 1998 {published data only}

Moreira 2002 {published data only (unpublished sought but not used)}

Oguz 1998 {published data only}

Redlich 2001 {published data only}

Wallin 1999 {published and unpublished data}

Xavier 1999 {published data only}

Referencias de los estudios en curso

CORONIS 2007 {published data only}

Referencias adicionales

Alderdice 2003

Anderson 2004

Finan 1991

Higgins 2005

Higgins 2011

Holmgren 1999

Joel‐Cohen 1977

Jokhan‐Jacob 2004

Kendall 1991

Kumar 1995

Mouchel 1981

Myerscough 1982

O'Grady 1995

RevMan 2003 [Computer program]

RevMan 2011 [Computer program]

Sreenivasan 2006

WHO 2000

Wood 1999

Referencias de otras versiones publicadas de esta revisión

Mathai 2006

Mathai 2007

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Characteristics of ongoing studies [ordered by study ID]

Data and analyses

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Instituciones a las que se accedió previamente

Usuarios institucionales

Instituciones a las que se accedió previamente

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