Surgical Techniques For Uterine Incision and Uterine Closure at

Surgical techniques for uterine incision and uterine closure at
the time of caesarean section (Review)

Dodd JM, Anderson ER, Gates S, Grivell RM
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2014, Issue 7
http://www.thecochranelibrary.com
Surgical techniques for uterine incision and uterine closure at the time of caesarean section (Review)
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 2.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 1
Febrile morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mean blood loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Duration of surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Duration of postnatal stay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wound complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.6. Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 6 Need
for blood transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endometritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.1. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 1
Postoperative febrile morbidity (including endometritis). . . . . . . . . . . . . . . . . . . .
Analysis 2.2. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 2 Mean
blood loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.3. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 3 Need
for blood transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.4. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 4 Maternal
death or serious morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.5. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 5
Duration of surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.1. Comparison 3 Methods of performing the uterine incision: transverse versus cephalad-caudad blunt extension,
Outcome 1 Mean blood loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outcome 2 Need for blood transfusion. . . . . . . . . . . . . . . . . . . . . . . . . .
Outcome 3 Duration of surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.1. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 1 Postoperative febrile
morbidity (including endometritis). . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.2. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 2 Blood loss greater
than 500 mL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.3. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 3 Need for blood
transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1
2
3
4
4
8
10
11
13
14
14
14
18
47
49
49
50
50
51
51
52
52
53
54
54
55
55
56
56
57
58
58
i
Analysis 4.4. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 4 Wound infection.
Analysis 4.5. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 5 Operative procedure
on wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.6. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 6 Postoperative
anaemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.7. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 7 Complication of
future pregnancy.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.8. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 8 Postoperative pain
present. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.9. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 9 Complications postop requiring re-laparotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.10. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 10 Length of hospital
stay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.11. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 11 Death or serious
maternal morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.12. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 12 Maternal
readmission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.1. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 1
Postoperative febrile morbidity (including endometritis). . . . . . . . . . . . . . . . . . . .
Analysis 5.2. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 2 Need for
blood transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.3. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 3 Wound
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.4. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 4 Operative
procedure on wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Postoperative pain present. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complications post-op requiring re-laparotomy. . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.7. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 7 Death or
serious maternal morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.8. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910, Outcome 8 Maternal
readmission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
60
61
61
62
63
63
64
64
65
66
66
67
67
68
68
69
69
70
70
70
71
71
71
ii
[Intervention Review]
Surgical techniques for uterine incision and uterine closure at

the time of caesarean section
Jodie M Dodd1 , Elizabeth R Anderson2 , Simon Gates3 , Rosalie M Grivell1
1 School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Womens and
Childrens Hospital, Adelaide, Australia. 2 Department of Genito-urinary Medicine, Royal Liverpool University Hospital, Liverpool,
UK. 3 Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
Contact address: Jodie M Dodd, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The
University of Adelaide, Womens and Childrens Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia.
jodie.dodd@adelaide.edu.au.
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 7, 2014.
Review content assessed as up-to-date: 1 September 2013.
Citation: Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD004732. DOI: 10.1002/14651858.CD004732.pub3.
ABSTRACT
Background
Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.
Objectives
To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and
technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and
healthcare resource use.
Search methods
We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (1 September 2013) and reference lists of all identified
papers.
Selection criteria
All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during
caesarean section.
Data collection and analysis
Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the
stated eligibility criteria and extracted data independently.
Main results
Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean
section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials
adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and
only six trials indicating blinding of outcome assessors.
Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in
febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval
(CI) 0.38 to 2.20).
Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving
2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt
or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies;
1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies;
1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.
A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean
blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69),
the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant
differences identified for the limited outcomes reported.
A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with
polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI
0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37
to 0.89).
Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the metaanalyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine
studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with
a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences
identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau =
0.15; I = 49%), or other reported clinical outcomes.
Authors conclusions
Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques,
short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques
they prefer and currently use.
PLAIN LANGUAGE SUMMARY

Surgical techniques involving the uterus at caesarean section
Caesarean section is a common abdominal operation for surgical delivery of a baby and the placenta. Techniques vary depending
on the clinical situation and surgeon preferences. Safe delivery is important for mother and infant. Any potential reduction of birth
trauma to the infant has to be balanced against increased ill-health for the mother. Factors include not only the duration of the surgical
procedure and maternal blood loss but also maternal postoperative pain, continuing blood loss and development of anaemia, fever and
wound infection. Additional complications can include problems with breastfeeding, passing urine, longer-term fertility problems, and
complications in future pregnancies (uterine rupture) or increased risks associated with future surgery.
The review authors searched the medical literature for randomised controlled trials to inform the most appropriate surgical techniques
to use. Twenty-seven trials involving 17,808 women from a number of different countries contributed to the review. None of these
trials assessed the type of uterine incision (side to side (transverse) lower uterine segment incision versus other types of uterine incision).
Results from 18 randomised trials contributed to reports that single layer closure of the uterine incision was associated with a reduction
in blood loss, and duration of the procedure. In these studies the surgical procedure for entering the abdominal cavity also differed and
could have contributed to blood loss and duration of surgery.
Five trials compared blunt with sharp dissection at the time of the uterine incision (2141 women) and a further two trials auto-suture
devices with standard hysterotomy (300 women). Blunt surgery was associated with a reduction in mean blood loss at the time of
the procedure. The use of an auto-suture instrument did not clearly reduce procedural blood loss but increased the duration of the
procedure. Overall, trials focused on blood loss and duration of the operative procedure rather than clinical outcomes for the women.
The methodological quality of the trials was variable.
BACKGROUND
Description of the condition

Caesarean section is a common major operation performed on
women in the world. Essentially, the operation involves exposing
the uterus by entering the abdominal cavity through the abdominal wall. The peritoneal lining of the abdomen is opened and
the peritoneum covering the uterus is usually also entered. The
bladder is reflected away from the uterus to reduce the chance of
damage to it during the operation. The uterus is then incised and
the baby and placenta delivered. Adequate haemostasis (control of
bleeding) is achieved by closure of the uterine muscle, followed by
closure of the abdominal wall.
Description of the intervention

There are many possible ways of performing a caesarean section
operation, and operative techniques vary widely. The techniques
used may depend on many factors, including the clinical situation and the preferences of the operator. Another Cochrane review providing an overview of the techniques, indications for caesarean section and postoperative complications, has been published (Hofmeyr 2008).
Our review specifically assessed surgical techniques involving the
uterus at the time at caesarean section, and included:
1. the type of uterine incision (lower transverse uterine
incision versus other types of uterine incision);
2. methods of performing the uterine incision (sharp uterine
entry versus blunt uterine entry);
3. suturing materials and techniques for the uterus at
caesarean section; and
4. single versus double layer suturing for closing the uterine
incision at caesarean section.
How the intervention might work
Part one: type of uterine incision at caesarean section

Part one of this review compares the outcomes of caesarean sections
performed using a transverse lower segment uterine incision with
other types of uterine incision (low vertical, classical, T-shaped
or J-shaped incision).
The transverse (side-to-side) lower segment uterine incision is
widely used in obstetric practice today. This incision has been
favoured because the lower uterine segment is less vascular than
the body of the uterus, and the incision is easier to repair. This
leads to a reduction in operative complications, especially haemorrhage, and also a reduction in morbidity. Lower segment incisions
are also associated with a lower incidence of uterine dehiscence or

rupture in subsequent pregnancies (Tahilramaney 1984).
The use of a low vertical uterine incision has been recommended
in certain clinical situations, particularly in delivery of the preterm
infant, where the lower uterine segment may be poorly formed
and the longitudinal incision may facilitate delivery and reduce
birth trauma by improved surgical access.
A classical uterine incision involves a vertical (up and down cut)
in the upper body of the uterus, and is used more rarely. It may be
used when the baby is in a transverse lie (that is, lying across the
mothers uterus), when the infant is preterm, or if there is an anterior placenta praevia (the placenta lies in the lower segment and on
the front wall of the uterus where the lower transverse uterine incision is usually made), but in practice, this incision is rarely used.
Haemorrhage is potentially more severe when an upper uterine
segment incision is used, and the repair often requires closure in
three layers as the myometrium (uterine muscle) is thicker in this
part of the uterus.
Occasionally, a transverse lower segment incision is made, and
during the operation, the incision needs to be extended in order to
obtain better surgical access, or to facilitate delivery of the infant.
In these situations, the incision may be extended vertically in the
midline, into the upper segment of the uterus forming an inverted
(upside-down) T-shaped incision. Alternatively, the incision may
be extended vertically from the end of the transverse incision to
form a J-shaped incision.
Potential injuries that may occur for the infant during a traumatic
caesarean birth include fractures, peripheral nerve damage, spinal
cord injury and subdural haematoma. Any potential reduction of
birth trauma to the infant has to be balanced against potential increased morbidity to the mother such as operative blood loss and
postoperative complications. In particular, consideration needs to
be given to mode of birth in any subsequent pregnancy. Uterine
rupture is a significant risk in a subsequent pregnancy or labour,
with estimates of occurrence being 4% to 9% for classical (uterine body, midline) caesarean incision; 4% to 9% for inverted Tshaped incisions; 1% to 7% for lower uterine segment vertical incisions; and 0.2% to 1.5% for lower uterine segment transverse
incisions (ACOG 1999). Current ACOG guidelines limit trial of
vaginal birth after caesarean section to women with a lower uterine segment transverse incision, and recommend repeat caesarean
birth for women with a prior classical or inverted T-shaped uterine
scar (ACOG 1999). Any consideration of the benefits associated
with a particular uterine incision must also consider the longerterm risks associated with repeat caesarean.
Part two: methods of performing the uterine incision
Part two of this review compares the outcomes of caesarean sections performed using different methods of incising the uterus
(including autostapling and sharp and blunt uterine entry).
When the uterus is incised at the time of caesarean section, the incision may be made in the centre of the lower uterine segment with
a scalpel and then extended laterally with scissors (sharp uterine

entry) or by digital extension (using the fingers) (blunt uterine
entry). There has been ongoing debate about which of these forms
of entry results in better maternal and infant outcomes (Rodriguez
1994). Theoretical benefits of sharp uterine entry include more
rapid delivery of the baby, and a more controlled entry, with less
likelihood of the incision extending into the broad ligament or
uterine vessels. The clean incision may also be easier to repair.
Proponents of blunt uterine entry argue that following the tissue
planes reduces blood loss and improves healing, and that dispensing with an instrument improves control over the entry.
Autostapling techniques involve the insertion of staples as the
surgical incision is made in order to keep the operating field as
bloodless as possible (Wilkinson 2006). The Auto Suture Poly
CS 57 Stapler was developed in the early 1990s. Its aim was to
achieve haemostasis through the placement of a double layer of
absorbable sutures before the uterine incision was made. The technique may be useful in particular circumstances, for example,
where the woman is infected with HIV, reducing contamination
with maternal blood and potentially reducing viral transmission
to the infant.
Part three: suturing materials and techniques for the
uterus
Part three of this review compares the outcomes of caesarean sections performed using different materials and techniques for closure of the uterine incision.
There are a range of suture materials and techniques used in surgical procedures, with the choice often resting with the preference
of the operator. For example, some advocate a single continuous
suture to close the uterus, which can be locked or not locked.
Others advocate multiple or interrupted sutures. Depending on
local resources and preference, different types of suture including monofilament and polyfilament/multifilament may be used to
close the uterus.
women. However, a recent observational study from Canada has

suggested that single layer closure of the lower uterine segment
at caesarean section is associated with a four-fold increase in the
risk of uterine rupture in a subsequent pregnancy when compared
with double layer uterine closure (odds ratio 3.95, 95% confidence
interval 1.35 to 11.49) (Bujold 2002).
Why it is important to do this review

Caesarean section is a common operation, with many different
methods of performing the surgery. It is important to assess the
benefits and harms associated with these different ways of performing the surgery.
OBJECTIVES
To compare, using the best available evidence, the effects of:
1. different types of uterine incision;
2. different methods of performing the uterine incision;
3. different materials and techniques for closure of the uterine
incision; and
4. single versus double layer closure of the uterine incision on
maternal or infant health, or both, and health care resource use.
METHODS
Criteria for considering studies for this review

Part four: single versus double layer suturing for
closing the uterine incision
Part four of this review compares the outcomes of caesarean sections performed using single layer closure of the uterine incision
with those using double layer closure.
One specific question about the technique used for uterine closure
is whether it should be closed with one layer of sutures or two. Traditionally, the transverse lower segment uterine incision is closed
in two layers (Enkin 2006). Those who advocate double closure
of the uterus cite improved haemostasis and wound healing, and
possibly a reduced risk of uterine rupture in a subsequent pregnancy. Single layer closure may be associated with reduced operating time, less tissue disruption, and less introduction of foreign
suture material into the wound. These potential advantages may
translate into reduced operative and postoperative morbidity for
Types of studies
All published, unpublished, and ongoing randomised controlled
trials comparing various types of uterine incision and closure of
the uterine incision during caesarean section.
We excluded quasi-randomised trials (e.g. those randomised by
date of birth or hospital number) from the analysis. Studies presented in abstract form only will not be included until the full
report becomes available to assess methodological quality and relevance to the scope of the review.
Types of participants
Women undergoing caesarean birth.
Types of interventions
1. Transverse lower uterine segment incision versus other types
of uterine incision.
2. Methods of performing the uterine incision (including
sharp versus blunt uterine entry; absorbable sutures versus
scissor or digital extension; direction of dissection (transverse
versus cephalad-caudad)).
3. Different materials or techniques, or both, for closure of the
uterine incision (including continuous suture versus interrupted
suture).
4. Single versus double layer closure of the uterine incision.
Types of outcome measures
Outcome measures for the infant (applicable to part one and

two of the review)
1.
2.
3.
4.
Neonatal death.
Birth trauma (as defined by trial authors).
Infant laceration.
Admission to neonatal intensive care unit and length of stay.
Health service use

1. Length of postoperative stay for the woman and infant.
2. Readmission to hospital of the woman or infant, or both.
Only outcomes with available data appear in the analysis table.
Only outcome data that were prestated by the review authors have
been used.
The methods section of this review is based on a standard template
used by the Cochrane Pregnancy and Chilbirth Group.
Primary outcomes
Postoperative febrile morbidity (as defined by trial authors).
Search methods for identification of studies
Secondary outcomes
Electronic searches
Outcome measures for the woman

1. Postoperative analgesia requirements (as defined by trial
authors).
2. Blood loss (as defined by trial authors).
3. Maternal death or serious maternal morbidity (e.g.
admission to intensive care unit).
4. Need for blood transfusion.
5. Wound infection (as defined by trial authors).
6. Wound complications (e.g. operative procedures carried out
on the wound; wound haematoma).
7. Postoperative pain (as measured by visual analogue scale or
need for additional analgesia).
8. Breastfeeding (at hospital discharge, or as defined by trial
authors).
9. Voiding problems (as defined by trial authors).
10. Duration of surgery.
11. Postoperative anaemia (as defined by trial authors).
12. Thromboembolic disease.
13. Complications during the postoperative period requiring
further surgery (re-laparotomy).
We searched the Cochrane Pregnancy and Childbirth Groups

Trials Register by contacting the Trials Search Co-ordinator (1
September 2013).
The Cochrane Pregnancy and Childbirth Groups Trials Register
is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. monthly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. weekly searches of Embase;
4. handsearches of 30 journals and the proceedings of major
conferences;
5. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL, MEDLINE and
Embase, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the Specialized Register section
within the editorial information about the Cochrane Pregnancy
and Childbirth Group.
Trials identified through the searching activities described above
are each assigned to a review topic (or topics). The Trials Search
Co-ordinator searches the register for each review using the topic
list rather than keywords.
Longer-term outcome measures for the woman

1. Future fertility problems.
2. Complications in a future pregnancy (e.g. placenta praevia,
placenta accreta, uterine rupture).
3. Complications at future surgery (e.g. adhesion formation).
Searching other resources

We conducted a manual search of the reference lists of all identified
papers.
We did not apply any language restrictions.
Data collection and analysis

For the methods used when assessing the trials identified in the
previous version of this review, see Appendix 1.
For this update we used the following methods when assessing the
reports identified by the updated search.
Selection of studies
Two review authors independently assessed for inclusion all the
potential studies we identified as a result of the search strategy. We
resolved any disagreement through discussion or, if required, we
consulted a third person.
Data extraction and management
We designed a form to extract data. For eligible studies, two review
authors extracted the data using the agreed form. We resolved
discrepancies through discussion or, if required, we consulted a
third person. We entered data into Review Manager software (
RevMan 2012) and checked it for accuracy.
When information regarding any of the above was unclear, we
planned to contact authors of the original reports to provide further details.
Assessment of risk of bias in included studies
Two review authors independently assessed risk of bias for each
study using the criteria outlined in the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2011). We resolved
any disagreement by discussion or by involving a third assessor.
(1) Random sequence generation (checking for possible
selection bias)
We described for each included study the method used to generate

the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups.
We assessed the method as:
low risk of bias (any truly random process, e.g. random
number table; computer random number generator);
high risk of bias (any non-random process, e.g. odd or even
date of birth; hospital or clinic record number);
unclear risk of bias.
(2) Allocation concealment (checking for possible selection
bias)
We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed
whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.
We assessed the methods as:
low risk of bias (e.g. telephone or central randomisation;

consecutively numbered sealed opaque envelopes);
high risk of bias (open random allocation; unsealed or nonopaque envelopes, alternation; date of birth);
(3.1) Blinding of participants and personnel (checking for

possible performance bias)
We described for each included study the methods used, if any, to

blind study participants and personnel from knowledge of which
intervention a participant received. We considered that studies
were at low risk of bias if they were blinded, or if we judged that the
lack of blinding was unlikely to affect results. We assessed blinding
separately for different outcomes or classes of outcomes.
low, high or unclear risk of bias for participants;
low, high or unclear risk of bias for personnel.
(3.2) Blinding of outcome assessment (checking for possible

detection bias)
We described for each included study the methods used, if any, to

blind outcome assessors from knowledge of which intervention a
participant received. We assessed blinding separately for different
outcomes or classes of outcomes.
We assessed methods used to blind outcome assessment as:
low, high or unclear risk of bias.
(4) Incomplete outcome data (checking for possible attrition

bias due to the amount, nature and handling of incomplete
outcome data)
We described for each included study, and for each outcome or

class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We stated whether attrition and exclusions were reported and the numbers included in the analysis at
each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes.
Where sufficient information was reported, or could be supplied
by the trial authors, we planned to re-include missing data in the
analyses which we undertook.
We assessed methods as:
low risk of bias (e.g. no missing outcome data; missing
outcome data balanced across groups);
high risk of bias (e.g. numbers or reasons for missing data
imbalanced across groups; as treated analysis done with
substantial departure of intervention received from that assigned
at randomisation);
(5) Selective reporting (checking for reporting bias)
We described for each included study how we investigated the

possibility of selective outcome reporting bias and what we found.
low risk of bias (where it is clear that all of the studys prespecified outcomes and all expected outcomes of interest to the
review have been reported);
high risk of bias (where not all the studys pre-specified
outcomes have been reported; one or more reported primary
outcomes were not pre-specified; outcomes of interest are
reported incompletely and so cannot be used; study fails to
include results of a key outcome that would have been expected
to have been reported);
(6) Other bias (checking for bias due to problems not

covered by (1) to (5) above)
We described for each included study any important concerns we

had about other possible sources of bias.
We assessed whether each study was free of other problems that
could put it at risk of bias:
low risk of other bias;
high risk of other bias;
unclear whether there is risk of other bias.
(7) Overall risk of bias
We made explicit judgements about whether studies were at high

risk of bias, according to the criteria given in the Handbook
(Higgins 2011). With reference to (1) to (6) above, we assessed the
likely magnitude and direction of the bias and whether we considered it likely to impact on the findings. We planned to explore the
impact of the level of bias through undertaking sensitivity analyses
- see Sensitivity analysis.
Unit of analysis issues
Cluster-randomised trials
We planned to include cluster-randomised trials in the analyses

along with individually-randomised trials. No cluster-randomised
trials were identified for this update. In future updates, if identified and analysed, we will adjust their sample sizes using the methods described in the Handbook [Section 16.3.4] using an estimate
of the intracluster correlation co-efficient (ICC) derived from the
trial (if possible), from a similar trial or from a study of a similar
population. If we use ICCs from other sources, we will report this
and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and
individually-randomised trials, we plan to synthesise the relevant
information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study
designs and the interaction between the effect of intervention and
the choice of randomisation unit is considered to be unlikely.
We will also acknowledge heterogeneity in the randomisation unit
and perform a sensitivity analysis to investigate the effects of the
randomisation unit.
Cross-over trials
Cross-over trials are not an appropriate study design for the interventions considered in this review.
Dealing with missing data
For dichotomous data, we presented results as summary risk ratio

with 95% confidence intervals.
For included studies, we noted levels of attrition. We planned to

explore the impact of including studies with high levels of missing
data in the overall assessment of treatment effect by using sensitivity analysis.
For all outcomes, we carried out analyses, as far as possible, on
an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention.
The denominator for each outcome in each trial was the number
randomised minus any participants whose outcomes were known
to be missing.
Continuous data
Assessment of heterogeneity
For continuous data, we used the mean difference if outcomes

were measured in the same way between trials. In future updates,
if appropriate, we will use the standardised mean difference to
combine trials that measure the same outcome, but use different
methods.
We assessed statistical heterogeneity in each meta-analysis using

the Tau, I and Chi statistics. We regarded heterogeneity as substantial if an I was greater than 30% and either a Tau was greater
than zero, or there was a low P value (less than 0.10) in the Chi
test for heterogeneity.
Measures of treatment effect
Dichotomous data
Assessment of reporting biases

For this update, there were not more than 10 studies in any metaanalysis. In future updates, if there are 10 or more studies in the
meta-analysis, we will investigate reporting biases (such as publication bias) using funnel plots. We will assess funnel plot asymmetry
visually. If asymmetry is suggested by a visual assessment, we will
perform exploratory analyses to investigate it.
Data synthesis
We carried out statistical analysis using the Review Manager software (RevMan 2012). We used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were
estimating the same underlying treatment effect: i.e. where trials
were examining the same intervention, and the trials populations
and methods were judged sufficiently similar. If there was clinical
heterogeneity sufficient to expect that the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we used random-effects meta-analysis to produce
an overall summary, if an average treatment effect across trials was
considered clinically meaningful. The random-effects summary
was treated as the average range of possible treatment effects and
we discussed the clinical implications of treatment effects differing
between trials. If the average treatment effect was not clinically
meaningful, we did not combine trials.
If we used random-effects analyses, the results were presented as
the average treatment effect with 95% confidence intervals, and
the estimates of Tau and I.
Subgroup analysis and investigation of heterogeneity
We did not carry out subgroup analysis for this update.
In future updates, if we identify substantial heterogeneity, we will
investigate it using subgroup analyses and sensitivity analyses. We
will consider whether an overall summary is meaningful, and if it
is, use random-effects analysis to produce it.
We plan to carry out the following subgroup analyses.
1. Planned (elective procedure, not in labour) versus
emergency procedures (procedures performed in labour,
including those women that had intended an elective operation
and now in spontaneous labour).
2. Primary versus subsequent caesarean section procedure.
Only the primary outcome will be used in subgroup analysis.
We will assess subgroup differences by interaction tests available
within RevMan (RevMan 2012). We will report the results of
subgroup analyses quoting the Chi statistic and P value, and the
interaction test I value.
Sensitivity analysis
We planned to carry out sensitivity analyses to explore the effect of
trial quality assessed by concealment of allocation, high attrition
rates (greater than 20%), or both, with poor-quality studies being
excluded from the analyses in order to assess whether this made

any difference to the overall result.
RESULTS
Description of studies
Results of the search
The search strategy identified 60 studies for consideration in this
review.
Included studies
Twenty-seven randomised controlled trials, involving 17,808
women undergoing caesarean section were included in this review (Batioglu 1998; Bjorklund 2000; CAESAR 2010; Ceci
2012; CORONIS 2013; Chitra 2004; Cromi 2008; Dani 1998;
Darj 1999; Ferrari 2001; Gutierrez 2008; Hamar 2007; Hauth
1992; Hidar 2007; Lal 1988; Magann 2002; Moreira 2002;
Poonam 2006; Rodriguez 1994; Sekhavat 2010; Sood 2005;
Studzinski 2002; Villeneuve 1990; Von Rechenberg 1990; Wallin
1999; Xavier 2005; Yasmin 2011). Information related to longerterm follow-up of women was available from the Hauth paper
(Chapman 1997) for the Hauth 1992 trial.
Types of uterine incision (transverse lower uterine segment
incision versus other types of uterine incision)
There were no studies identified making this comparison in relation to type of uterine incision.
Methods of performing the uterine incision (including sharp
versus blunt uterine entry; absorbable sutures versus
scissor or digital extension; direction of blunt dissection:
transverse versus cephalad-caudad)
Five studies were included in the review making the comparison

between methods of performing the uterine incision (Hidar 2007;
Magann 2002; Poonam 2006; Rodriguez 1994; Sekhavat 2010).
All compared blunt versus sharp dissection at the time of uterine incision, involving women from the United States (Magann
2002; Rodriguez 1994), Tunisia (Hidar 2007), Nepal (Poonam
2006), and Iran (Sekhavat 2010). Two studies were identified involving the use of the Autosuture Poly CS 57 automatic surgical
stapler compared with standard hysterotomy, involving women
from Canada (Villeneuve 1990) and Switzerland (Von Rechenberg
1990). A single study compared the direction of blunt extension of
the uterine incision (transverse versus cephalad-caudad), involving
women from Italy (Cromi 2008). All studies were single centre.
Different materials or techniques, or both, for closure of the

uterine incision (including continuous suture versus
interrupted suture)
One study was identified that compared continuous suture closure

with interrupted suture closure of the uterine incision (Ceci 2012).
Women were followed until 24 months postpartum but only ultrasound and hysteroscopic assessments were reported. One study
was identified that compared two different types of material for
closure of the uterine incision (CORONIS 2013). In this study,
chromic catgut was compared with number 1 polygactin-910 in
almost 10,000 women (this closure could be with interrupted or
continuous sutures).
Single versus double layer closure of the uterine incision
Nineteen studies were identified comparing single layer with double layer closure of the uterus (Batioglu 1998; Bjorklund 2000;
CAESAR 2010; CORONIS 2013; Chitra 2004; Dani 1998; Darj
1999; Ferrari 2001; Gutierrez 2008; Hamar 2007; Hauth 1992;
Lal 1988; Moreira 2002; Poonam 2006; Sood 2005; Studzinski
2002; Wallin 1999; Yasmin 2011; Xavier 2005). These studies
were conducted in Tanzania (Bjorklund 2000), Tunisia (Hidar
2007), Senegal (Moreira 2002), the United Kingdom (CAESAR
2010), United States of America (Hamar 2007; Hauth 1992), India (Chitra 2004; Lal 1988; Sood 2005), Nepal (Poonam 2006),
Mexico (Gutierrez 2008), Turkey (Batioglu 1998), Italy (CAESAR
2010; Dani 1998; Ferrari 2001), Poland (Studzinski 2002), Senegal (Moreira 2002), Portugal (Xavier 2005), and Sweden (Darj
1999; Wallin 1999). With the exception of the CAESAR study
(CAESAR 2010), and the CORONIS study (CORONIS 2013),
all were single centre. The study by Yasmin and colleagues (Yasmin
2011) focused on ultrasound follow-up of the uterine scar, outcomes which were not pre-specified in this review. The study by
Dani and colleagues (Dani 1998) reported short-term infant outcomes after caesarean section, but none of these outcomes were
prespecified in the review.
For details of the included studies, see the table of Characteristics
of included studies.
Excluded studies
Twenty-six studies were excluded from the review, with 14

studies using quasi-randomised methods of treatment allocation
(Ansaloni 2001; Baxter 2008; Behrens 1997; Dargent 1990;
Falls 1958; Gaucherand 2001; Hameed 2004; Heidenreich 1995;
Hoskins 1991; Kiefer 2008; Lodh 2002; Ohel 1996; Redlich
2001; Van Dongen 1989; ). Eleven studies were excluded as the
comparisons did not involve surgical techniques on the uterus
(Buhimschi 2006; Decavalas 1997; Doganay 2010; Gedikbasi
2011; Ghezzi 2001; Giacalone 2002; Hohlagschwandtner;
Malvasi 2011; Moroz 2008; Naki 2011; Ozbay 2011). One study
did not utilise intention-to-treat principles for data analysis, and
it was not possible from the information provided to restore participants to their randomised groups (Heimann 2000).
For details of the excluded studies, see the table of Characteristics
of excluded studies.
Studies awaiting assessment and ongoing studies
Several reports were identified in abstract form only, with insufficient information available to allow assessment for inclusion in this review (Borowski 2007; Hagen 1999; Mazhar 2004;
Mukhopadhyay 2000; Pandey 2006; Wojdemann 2010); another
trial report is in Polish and is awaiting translation (Belci 2005)
(see Studies awaiting classification), In addition, we identified one
trial registration (Farajzadeh 2010) (see Characteristics of ongoing
studies).
Risk of bias in included studies

Overall, the methodological quality of the trials was variable (see
Description of studies and Characteristics of included studies).
There was variable reporting of the prespecified outcomes of the
review, with 21 trials presenting information that could be incorporated into the meta-analysis (Batioglu 1998; Bjorklund 2000;
CAESAR 2010; CORONIS 2013; Chitra 2004; Cromi 2008;
Ferrari 2001; Gutierrez 2008; Hamar 2007; Hauth 1992; Hidar
2007; Magann 2002; Moreira 2002; Poonam 2006; Rodriguez
1994; Sekhavat 2010; Studzinski 2002; Villeneuve 1990; Von
Rechenberg 1990; Wallin 1999; Xavier 2005).
See Figure 1; and Figure 2 for a summary of Risk of bias assessments.
Figure 1. Risk of bias graph: review authors judgements about each risk of bias item presented as
percentages across all included studies.
10
Figure 2. Risk of bias summary: review authors judgements about each risk of bias item for each included
study.
11
Allocation
While all of the studies were stated to be randomised, the method
of randomisation was adequately described in 13 trials as involving either computer-generated randomisation sequences or tables of random numbers (Bjorklund 2000; CAESAR 2010; Ceci
2012; CORONIS 2013; Cromi 2008; Hauth 1992; Hidar 2007;
Magann 2002; Sekhavat 2010; Sood 2005; Villeneuve 1990;
Wallin 1999; Xavier 2005). The method of allocation concealment
was assessed as adequate in 13 trials, with 11 utilising sequentially
numbered, sealed, opaque envelopes (Bjorklund 2000; Darj 1999;
Ferrari 2001; Hamar 2007; Hauth 1992; Hidar 2007; Magann
2002; Sekhavat 2010; Sood 2005; Villeneuve 1990; Wallin 1999),
and two telephone randomisation (CAESAR 2010; CORONIS
2013).
Blinding
Blinding of outcome assessor was indicated in only six of the trials
(CAESAR 2010; Ceci 2012; Dani 1998; Sood 2005; Wallin 1999;
Xavier 2005). Blinding of both participants and personnel was not
indicated in any of the included trials. Participants were blinded
in one trial (Sekhavat 2010).
Incomplete outcome data

Most included studies were assessed as at low risk of bias due to
incomplete outcome data, with three being assessed as unclear risk.
Selective reporting
Most included studies were assessed as at low risk of bias for selective reporting, however, four studies were assessed as having an
unclear risk of selective reporting bias.
Other potential sources of bias

The CEASAR trial was identified as at potential risk of bias, having modified the primary outcome of the trial after 600 women
were recruited, and as the trial was stopped short of the total estimated sample size (CAESAR 2010). The trial by Xavier (Xavier
2005) recruited and randomised 162 women, with outcome data
reported for only 72.
Effects of interventions
Twenty-seven randomised controlled trials, involving 17,808
women undergoing caesarean section were included in this review,
as described below.
Methods of performing the uterine incision (including

sharp versus blunt uterine entry and absorbable
sutures versus scissor or digital extension)
Automatic stapler versus conventional uterine incision
Two trials (Villeneuve 1990; Von Rechenberg 1990) compared

auto-suture devices with traditional hysterotomy involving 300
women. It was only possible to combine data from the two trials
included for the primary outcome, febrile morbidity. No statistically significant difference between the stapler and conventional
incision groups was apparent (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.38 to 2.20), Analysis 1.1. Other outcomes
included data from only one study. There is a suggestion of a lower
blood loss in the stapler group in Villeneuve 1990 (mean difference (MD) -87.00 mL, 95% CI -175.09 to 1.09), Analysis 1.2;
however, the lack of blinding means that bias in the assessment of
this outcome cannot be excluded.
Blunt versus sharp extension of the uterine incision
Five trials compared blunt with sharp extension of the uterine incision, involving 2141 women (Hidar 2007; Magann 2002; Poonam
2006; Rodriguez 1994; Sekhavat 2010). There were no statistically
significant differences identified for the primary outcome febrile
morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05),
Analysis 2.1. Mean blood loss (two studies; 1145 women; average MD -55.00 mL; 95% CI -79.48 to -30.52; Heterogeneity:
Tau = 160.80; I = 51%), Analysis 2.2, and the need for blood
transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to
0.62), Analysis 2.3, were significantly lower following blunt extension, with no other significant differences identified in duration of operative procedure (one study; 200 women; MD -2.80
minutes; 95% CI -5.84 to 0.24), Analysis 2.5, or risk of serious
maternal morbidity (one study; 400 women; RR 3.00; 95% CI
0.12 to 73.20), Analysis 2.4.
Direction of blunt extension of the uterine incision:

transverse versus cephalad-caudad
A single trial compared transverse with cephalad-caudad blunt

extension of the uterine incision, involving 811 women (Cromi
2008). While mean blood loss was reported to be lower following
transverse extension (one study; 811 women; MD 42.00 mL; 95%
CI 1.31 to 82.69), Analysis 3.1, the clinical significance of such
a small volume difference is of uncertain clinical relevance. There
were no other statistically significant differences identified for the
limited outcomes reported.
12
Single versus double layer closure of the uterine

incision
Nineteen studies were identified comparing single layer with double layer closure of the uterus (Batioglu 1998; Bjorklund 2000;
CAESAR 2010; CORONIS 2013; Chitra 2004; Dani 1998; Darj
1999; Ferrari 2001; Gutierrez 2008; Hamar 2007; Hauth 1992;
Lal 1988; Moreira 2002; Poonam 2006; Sood 2005; Studzinski
2002; Wallin 1999; Yasmin 2011; Xavier 2005), with data contributed to the meta-analyses from 14 studies. The reported standard deviations for continuous variables reported in Ferrari 2001
were considered to be far too small to be plausible, and we believe
that the authors have erroneously reported standard errors rather
than standard deviations. We have therefore, converted the standard errors to standard deviations by dividing the square root of
the sample size for inclusion of these data in the analyses.
There were no statistically significant differences identified for the
primary outcome, febrile morbidity (nine studies; 13,890 women;
RR 0.98; 95% CI 0.85 to 1.12), Analysis 4.1. For the outcome
of mean blood loss, although the meta-analysis suggested single
layer closure sure was associated with a reduction in mean blood
loss, heterogeneity is high and this limits the clinical applicability
of the result. There were no differences identified in risk of blood
transfusion (four studies; 13,571 women; average RR 0.86; 95%
CI 0.63 to 1.17; Heterogeneity: Tau = 0.03; I = 30%), Analysis
4.3. There were no other significant differences identified in the
reported clinical outcomes.
Suturing materials and techniques for uterine closure

(including continuous suture versus interrupted
suture)
One study was identified that compared continuous versus interrupted suture closure for the uterine incision (Ceci 2012), however, no clinical maternal outcomes were reported, with ultrasound
and hysteroscopic assessments forming the main focus of the paper. The single trial comparing chromic catgut with polygactin910 reported on outcomes in 9544 women (CORONIS 2013) .
Closure with catgut was associated with a significant reduction in
the need for blood transfusion (one study, 9544 women, RR 0.49,
95% CI 0.32 to 0.76), Analysis 5.2. and a significant reduction in
complications requiring re-laparotomy (one study, 9544 women,
RR 0.58, 95% CI 0.37 to 0.89); Analysis 5.6. There were no other
significant differences in the other reported outcomes.
It was not possible to conduct the planned subgroup analyses.
DISCUSSION
Summary of main results
While caesarean section is a common procedure performed on

women worldwide, there is limited information available to inform
the most appropriate surgical technique to adopt. Our review did
not identify any randomised controlled trials assessing the type
of uterine incision to be used (transverse lower uterine segment
incision versus other types of uterine incision), the materials used
to suture the uterus, or techniques of suture closure (continuous
suture versus interrupted suture; locking versus unlocked suture).
While blunt dissection of the uterine incision was associated with
a reduction in the mean blood loss at the procedure and the need
for blood transfusion, there were no other differences identified in
clinical outcomes. The use of an auto-suture device was associated
with a reduction in the mean blood loss at the procedure, but an
increase in the duration of the procedure when compared with
performing a traditional hysterotomy. Similarly, there were no statistically significant differences identified in the clinical outcomes
reported.
Closure of the uterus with chromic catgut was associated with a
reduction in blood transfusion and complications requiring re-laparotomy, however, there was no significant difference in any other
clinical outcomes. The only trial making this comparison allowed
surgeons to use any suture technique, i.e. continuous, continuous
locking and interrupted sutures and this is an important potential
confounder for these outcomes.
Although single layer closure of the uterine incision was associated
with a reduction in mean blood loss, and duration of the operative
procedure, there were no statistically significant differences identified in the risk of febrile morbidity and other clinically relevant
outcomes. Most of the studies involved in this comparison were
assessing different methods of performing the whole caesarean
section operation (for example, a whole procedure technique,
which includes as one aspect the single layer closure versus another
whole procedure technique that includes a double layer closure).
Different components of these procedures involve variation in the
methods used to enter the abdominal cavity, which in turn may
influence the extent of blood loss, and duration of the procedure.
Overall completeness and applicability of

evidence
Overall, reporting of the prespecified review outcomes was poor,
with the majority of trials focusing on estimates of mean blood
loss and duration of the operative procedure, rather than measures
reflecting health outcomes. For many of the outcomes, reporting
was from a single trial, with relatively small combined sample size.
Quality of the evidence

Overall, the methodological quality of the trials was variable, with
12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods
13
of allocation concealment, and only six trials indicating blinding

of outcome assessors.
Agreements and disagreements with other

studies or reviews
The literature describing and assessing caesarean section surgical
techniques is broad and in general of low quality, and as such the
current review is in general agreement with most other studies and
reviews in this area.
Caesarean section is a common procedure performed on women

worldwide. There is increasing evidence that for many techniques,
short-term maternal outcomes are equivalent. Until long-term
health effects are known, surgeons should continue to use the techniques they prefer and currently use.
Implications for research

Future randomised controlled trials and future follow-up of
women in existing trials should address:
the most appropriate uterine incision;
the optimal suture technique to close the uterus;
AUTHORS CONCLUSIONS
the value of blunt compared with sharp uterine dissection;

and
Implications for practice
the value of single compared with double layer uterine

closure.
Despite caesarean section being a common operation, for many

aspects of the procedure, there is limited high quality information
available to suggest that one surgical technique is superior to another. There is no information available to inform the most appropriate uterine incision. There is little information to support
the most appropriate method of performing the uterine incision
(blunt versus sharp dissection) or to support the use of an autosuture device. There is limited information available to inform
the optimal suture technique for the uterine incision. Consideration should be given to suture material for uterine closure, as
closure with chromic catgut was associated with a lower risk of
blood transfusion, when compared with polygactin-910, with no
difference in other clinical outcomes.
Any future randomised trials should be adequately powered to

detect important differences in clinically relevant outcomes.
ACKNOWLEDGEMENTS
As part of the pre-publication editorial process, this review has
been commented on by six peers (an editor and five referees who
are external to the editorial team), a member of the Pregnancy
and Childbirth Groups international panel of consumers and a
statistician.
REFERENCES
References to studies included in this review

Batioglu 1998 {published data only}
Batioglu S, Kuscu E, Duran EH, Haberal A. One-layer
closure of low segment transverse uterine incision by the
Lembert technique. Journal of Gynecologic Surgery 1998;14:
114.
surgical techniques: a randomised factorial trial (CAESAR).

BJOG: an international journal of obstetrics and gynaecology
2010;117(11):136676.
National Perinatal Epidemiology Unit. The CAESAR
Study. www.npeu.ok.ac.uk/trials/caesar.html (accessed
2001).
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 controlled trial.
British Journal of Obstetrics and Gynaecology 2000;107(2):
20916.
Ceci 2012 {published data only}

Ceci O, Cantatore C, Scioscia M, Nardelli C, Ravi M,
Vimercati A, et al.Ultrasonographic and hysteroscopic
outcomes of uterine scar healing after cesarean section:
comparison of two types of single-layer suture. Journal of
Obstetrics and Gynaecology Research 2012;38(11):13027.
CAESAR 2010 {published data only}

Brocklehurst P. The CAESAR study: a randomised
controlled trial of caesarean section surgical techniques
[abstract]. 31st British International Congress of Obstetrics
and Gynaecology; 2007 July 4-6; London, UK. 2007:31.
CAESAR study collaborative group. Caesarean section
Chitra 2004 {published data only}

Chitra KLS, Nirmala AP, Gayetri R, Jayanthi NV, Shanthi
JS. Misgav Ladach cesarean section vs Pfannenstiel cesarean
section. Journal of Obstetrics and Gynecology of India 2004;
54(5):4737.
14
CORONIS 2013 {published data only}

Brocklehurst P, for the CORONIS Trial Collaborative
Group. The CORONIS Trial: International study of
caesarean section surgical techniques: a randomised
fractional factorial randomised trial. BJOG: an international
journal of obstetrics and gynaecology 2013;120(Suppl 1):3.
CORONIS Collaborative Group. Caesarean section

surgical techniques (CORONIS): a fractional, factorial,
unmasked, randomised controlled trial. Lancet 2013;382:
23448.
Glavind J, Uldbjerg N. Caesarean section: in good surgical
skills we trust. Lancet 2013;382:1889.
Juszczak E, Farrell B. The CORONIS Trial: international
study of caesarean section surgical techniques. Trials 2011;
112(Suppl 1):A103.
National Perinatal Epidemiology Unit. Prevention of
maternal morbidity after caesarean section in developing
countries: a factorial RCT of surgical methods. http://
www.npeu.ox.ac.uk/coronis/ accessed 2008.
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.
Cromi 2008 {published data only}
Cromi A, Di Naro E, Siesto G, Uccella S, Caringella A,
Uboldi V, et al.Expansion of uterine incision at cesarean
delivery: a randomized comparison of two techniques.
American Journal of Obstetrics and Gynecology 2007;197(6
Suppl 1):S36, Abstract no: 79.
Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G,

Bolis P. Blunt expansion of the low transverse uterine
incision at cesarean delivery: a randomized comparison of 2
techniques. American Journal of Obstetrics and Gynecology
2008;199(3):292.e16.
Dani 1998 {published data only}
Dani C, Reali M, Oliveto R, Temporin G, Bertini G,
Rubaltelli F. Short-term outcome of newborn infants born
by a modified procedure of cesarean section: a prospective
randomized study. Acta Obstetricia et Gynecologica
Scandinavica 1998;77:92931.
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):3741.
Ferrari 2001 {published data only}
Ferrari A, Frigerio L, 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:
13543.
Gutierrez 2008 {published data only}
Gutierrez JG, Colo JA, Arreola MS. Comparative trial
between traditional cesarean section and Misgav-Ladach
technique [Comparacin entre cesarea MisgavLadach y
cesarea tradicional]. Ginecologia y Obstetricia de Mexico
2008;76(2):7580.
Hamar 2007 {published data only}
Hamar BD, Saber SB, Cackovic M, Magloire LK, Pettker

CM, Abdel-Razeq SS, et al.Ultrasound evaluation of the
uterine scar after cesarean delivery. Obstetrics & Gynecology
2007;110:80813.
Hamar BR, Saber SB, Cackovic M, Magloire LK, Pettker
CM, Abdel-Razeq SS, et al.Ultrasound evaluation of uterine
incision healing after cesarean delivery - a randomized
controlled study of one-versus two-layer closure. American
Journal of Obstetrics and Gynecology 2006;195(6 Suppl 1):
S57.
Hauth 1992 {published data only}
Chapman SJ, Owen J, Hauth JC. One- versus two-later
closure of a low transverse cesarean: the next pregnancy.
Obstetrics & Gynecology 1997;89:168.
Hauth JC, Owen J, Davis RO. Transverse uterine incision

closure: one vs two layers. American Journal of Obstetrics
and Gynecology 1992;167:110811.
Hauth JC, Owen J, Davis RO, Lincoln T. Transverse uterine
incision closure: one vs two layers. American Journal of
Obstetrics and Gynecology 1991;164:407.
Hauth JC, Owen J, Davis RO, Lincoln T, Piazza J.
Transverse uterine incision closure: one vs two layers.
American Journal of Obstetrics and Gynecology 1992;166:
398.
Hidar 2007 {published data only}
Hidar S, Jerbi M, Hafsa A, Slama A, Bibi M, Khairi H. The
effect of uterine incision expansion at caesarean delivery
on perioperative haemorrhage: a prospective randomised
clinical trial. Revue Medicale de Liege 2007;62(4):2358.
Lal 1988 {published data only}
Lal K, Tsomo P. Comparative study of single layer and
conventional closure of uterine incision in cesarean section.
International Journal of Gynecology & Obstetrics 1988;27:
34952.
Magann 2002 {published data only}
Magann E, Chauhan S, Bufkin L, Field K, Roberts W,

Martin JP Jr. Intra-operative haemorrhage by blunt verus
sharp expansion of the uterine incision at caesarean delivery:
a randomised clinical trial. BJOG: an international journal
of obstetrics and gynaecology 2002;109:44852.
Magann E, Chauhan S, Bufkin L, Fields K, Roberts W,
Martin JJ. Sharp versus blunt expansion of the uterine
incision: influence on blood loss [abstract]. American
Journal of Obstetrics and Gynecology 2001;184(1):S18.
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 [Comparaison de
deux techniques de cesarienne: cesarienne classique
versus cesarienne Misgav Ladach]. Journal de Gynecologie,
Obstetrique et Biologie de la Reproduction 2002;31(6):5726.
Poonam 2006 {published data only}
Poonam, Banerjee B, Singh SN, Raina A. The Misgav
Ladach method: a step forward in the operative technique
15
of caesarean section. Kathmandu University Medical Journal

2006;4(2):198202.
Rodriguez 1994 {published data only}
Rodriguez A, Porter KB, OBrien WF. Digital vs
instrumental expansion of the uterine incision at the time of
a low segment transverse cesarean section. American Journal
of Obstetrics and Gynecology 1994;170:339.
Rodriguez AI, Porter KB, OBrien WF. Blunt versus

sharp expansion of the uterine incision in low-segment
transverse cesarean section. American Journal of Obstetrics
and Gynecology 1994;171:10225.
Sekhavat 2010 {published data only}
Sekhavat L, Firouzabadi RD, Mojiri P. Effect of expansion
technique of uterine incision on maternal blood loss in
cesarean section. Archives of Gynecology and Obstetrics 2010;
282:4759.
Sood 2005 {published data only}
Sood AK. Single versus double layer closure of low transverse
uterine incision and caesarean section. Journal of Obstetrics
and Gynaecology of India 2005;55(3):2316.
Studzinski 2002 {published data only}
Studzinski Z. The Misgav-Ladach method for cesarean
section compared to the Pfannenstiel technique [Ciecie
cesarskie sposobem MisgavLadach w porownaniu z
technika Pfannenstiela]. Ginekologia Polska 2002;73(8):
6726.
Villeneuve 1990 {published data only}
Villeneuve MG, Khalife S, Marcoux S, Blanchet P. Surgical
staples in cesarean section: a randomized controlled trial.
American Journal of Obstetrics and Gynecology 1990;163:
16416.
Von Rechenberg 1990 {published data only}
Von Rechenberg KN. Use of a stapler for hysterotomy
in Cesarean section [Die Anwendung eines
Klammernahtinstrumentes fur die Hysterotomie bei
der Sectio Caesarea]. Zeitschrift fur Geburtshilfe und
Perinatologie 1990;194:859.
Wallin 1999 {published data only}
Wallin G, Fall O. Modified Joel-Cohen technique

for caesarean delivery. British Journal of Obstetrics and
Gynaecology 1999;106(3):2216.
Wallin G, Fall O. Modified Joel-Cohen technique for
caesarean section. A prospective randomised study. Acta
Obstetricia et Gynecologica Scandinavica Supplement 1997;
76(167:2):24.
Xavier 2005 {published data only}
Ayres-de-Campos D, Patricio B. Modifications to the
Misgav Ladach technique for cesarean section. Acta
Obstetricia Gynecologica Scandinavica 2000;79:3267.
Xavier P, Ayres-De-Campos D, Reynolds A, Guimaraes

M, Costa-Santos C, Patricio B. The modified MisgavLadach versus the Pfannensteil-Kerr technique for cesarean
section: a randomized trial. Acta Obstetricia et Gynecologica
Scandinavica 2005;84(9):87882.
Yasmin 2011 {published data only}

Yasmin S, Sadaf J, Fatima N. Impact of methods for uterine
incision closure on repeat caesarean section scar of lower
uterine segment. Jcpsp, Journal of the College of Physicians &
Surgeons - Pakistan 2011;21(9):5226.
References to studies excluded from this review

Ansaloni 2001 {published data only}
Ansaloni L, Brundisini R, Morino G, Kiura A. Prospective,
randomized, comparative study of misgav ladach versus
traditional cesarean section at Nazareth Hospital, Kenya.
World Journal of Surgery 2001;25(9):116472.
Baxter 2008 {published data only}
Baxter JK. Comparison of tissue retractors during cesarean
delivery in obese women. http://clinicaltrials.gov/ct2/show/
NCT00358592 (accessed 20 February 2008).
Behrens 1997 {published data only}
Behrens D, Zimmerman S, Stoz F, Holzgreve W.
Conventional versus cohen-stark: a randomised comparison
of the two techniques for cesarean section. 20th Congress of
the Swiss Society of Gynecology and Obstetrics; 1997 June;
Lugano, Switzerland. 1997:14.
Buhimschi 2006 {published data only}
Buhimschi CS, Buhimschi IA, Zhao G, Funai EF, Peltecu
G, Saade GR, et al.Structural and biomedical properties of
the lower uterine segment above and below the reflection
of the urinary bladder at cesarean section (CS). American
S89.
Dargent 1990 {published data only}
Dargent D, Audra P, Noblot G. Utilisation of the Poly CS57
clip for Caesarean section. A randomised trial. Journal de
Gynecologie, Obstetrique et Biologie de la Reproduction 1990;
18:9612.
Decavalas 1997 {published data only}
Decavalas G, Papadopoulos V, Tzingounis V. A prospective
comparison of surgical procedures in cesarean section. Acta
Obstetricia et Gynecologica Scandinavica 1997;76(167):13.
Doganay 2010 {published data only}
Doganay M, Tonguc EA, Var T. Effects of method of
uterine repair on surgical outcome of cesarean delivery.
International Journal of Gynecology & Obstetrics 2010;111
(2):1758.
Falls 1958 {published data only}
Falls F. Recent advances in obstetric and gynecologic
surgery. Journal of the American Medical Association 1958;
166:140912.
Gaucherand 2001 {published data only}
Gaucherand P, Bessai K, Sergeant P, Rudigoz RC. Towards
simplified cesarean section? [Vers une simplification de
loperation cesarienne?]. Journal de Gynecologie, Obstetrique
et Biologie de la Reproduction 2001;30(4):34852.
Gedikbasi 2011 {published data only}
Gedikbasi A, Akyol A, Ulker V, Yildirim D, Arslan O,
Karaman E, et al.Cesarean techniques in cases with one
16
previous cesarean delivery: comparison of modified MisgavLadach and Pfannenstiel - Kerr. Archives of Gynecology and
Obstetrics 2011;283(4):7116.
caesarean section on repeat caesarean delivery. European

Journal of Obstetrics & Gynecology and Reproductive Biology
2011;159(2):3004.
Ghezzi 2001 {published data only}

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.
Giacalone 2002 {published data only}
Giacalone PL, Daures JP, Vignal J, Herisson C, Hedon
B, Laffargue F. Pfannenstiel versus maylard incision for
cesarean delivery: a randomized controlled trial. Obstetrics
& Gynecology 2002;99:74550.
Moroz 2008 {published data only}

Moroz L, Bowers G, Hayes EJ, OBrien J, Carroll T, Baxter
JK. Self-retained compared with traditional retractors for
cesarean delivery in obese women, a randomized controlled
trial. Obstetrics & Gynecology 2008;111(4 Suppl):101S.
Hameed 2004 {published data only}

Hameed N, Ali MA. Maternal blood loss by expansion of
uterine incision at caesarean section--a comparison between
sharp and blunt techniques. Journal of Ayub Medical College
Abbottabad 2004;16(3):4750.
Ohel 1996 {published data only}

Ohel G, Younis JS, Lang N, Levit A. Double-layer closure of
uterine incision with visceral and parietal peritoneal closure:
are they obligatory steps of routine cesarean sections?.
Journal of Maternal-Fetal Medicine 1996;5(6):3669.
Heidenreich 1995 {published data only}

Heidenreich W, Bruggenjurgen K. Modified Sarafoff suture
for single layer closure of uterotomy in cesarean section. A
prospective study. Zentralblatt fur Gynakologie 1995;117:
404.
Heimann 2000 {published data only}
Heimann J, Hitschold T, Muller K, Berle P. Randomized
trial of the modified misgav-ladach and the conventional
pfannensteil techniques for cesarean section. Geburtshilfe
und Frauenheilkunde 2000;60:24250.
Hohlagschwandtner {published data only}
Hohlagschwandtner M, Chalubinski K, Nather A,
Husslein P, Joura EA. Sonographic findings after cesarean
section without formation of a bladder flap [Sectio
caesarea ohne Blasenpraparation: Eine sonographische
Nachuntersuchung.]. Geburtshilfe und Frauenheilkunde
2002;62(2):1636.
Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura

E. Is the formation of a bladder flap at cesarean necessary?
A randomized trial. Obstetrics & Gynecology 2001;98:
108992.
Hoskins 1991 {published data only}
Hoskins IA, Ordorica SA, Frieden FJ, Young BK.
Performance of Cesarean section using absorbable staples.
Surgery, Gynecology and Obstetrics 1991;172:10812.
Kiefer 2008 {published data only}
Kiefer DG. A multicenter, randomized, controlled trial of
Seprafilm adhesion barrier to reduce adhesion formation
following cesarean delivery. http://clinicaltrials.gov/ct2/
show/NCT00565643 (accessed 20 February 2008).
Lodh 2002 {published data only}
Lodh E, Bhattacharjee P. Single layer closure of caesarean
section - a comparative study. Journal of Obstetrics and
Gynaecology of India 2002;52(2):356.
Malvasi 2011 {published data only}
Malvasi A, Tinelli A, Guido M, Cavallotti C, Delledera D,
Zizza A, et al.Effect of avoiding bladder flap formation in
Naki 2011 {published data only}

Naki MM, Api O, Celik H, Kars B, Yasar E, Unal O.
Comparative study of Misgav-Ladach and PfannenstielKerr cesarean techniques: a randomized controlled trial.
Journal of Maternal-Fetal and Neonatal Medicine 2011;24
(2):23944.
Ozbay 2011 {published data only}

Ozbay K. Exteriorized versus in-situ repair of the uterine
incision at cesarean delivery: a randomized controlled trial.
Clinical and Experimental Obstetrics and Gynecology 2011;
38(2):1558.
Redlich 2001 {published data only}
Redlich A, Koppe I. The gentle caesarean section - an
alternative to the classical way of section. A prospective
comparison between the classical technique and the method
of misgav ladach [Die sanfte Sectio Eine Alternative
zur klassischen Sectiotechnik Prospektiver Vergleich der
klassischen Technik mit der MisgavLadachMethode].
Zentralblatt fur Gynakologie 2001;123(11):63843.
Van Dongen 1989 {published data only}
Van Dongen P, Nijhuis J, Jongsma H. Reduced blood
loss during caesarean section due to a controlled stapling
technique. Acta Obstetricia et Gynecologica Scandinavica
1997;76(167):20.
Van Dongen PWJ, Nijhuis JG, Jongsma HW. Reduced
blood loss during Caesarean section due to a controlled
stapling technique. European Journal of Obstetrics &
Gynecology and Reproductive Biology 1989;32:95102.
References to studies awaiting assessment

Belci 2005 {published data only}
Belci D, Kos M, Zoricic D, Kuharic L, Slivar A, BegicRazem E, et al.Misgav Ladach surgical technique of cesarean
section: our experience at Pula General Hospital [Carski
rez po misgav ladachu: Iskustva u Puli]. Gynaecologia et
Perinatologia 2005;14(4):1718.
Borowski 2007 {published data only}
Borowski K, Andrews J, Hocking M, Hansen W, Fleener D,
Syrop C. Ultrasonographic detection of cesarean scar defects
in a trial of single versus double layer closure. American
S62, Abstract no: 183.
17
Hagen 1999 {published data only}

Hagen A, Schmid O, Runkel S, Weitzel H, Hopp H. A
randomized trial of two surgical techniques for cesarean
section. European Journal Obstetrics & Gynecology and
Reproductive Biology 1999;86:S81.
Mazhar 2004 {published data only}
Mazhar SB, Mahsood S. Single versus double layer uterine
closure during cesarean section: a randomised trial. 30th
British Congress of Obstetrics and Gynaecology; 2004 July
7-9; Glasgow, UK. 2004:63.
Mukhopadhyay 2000 {published data only}
Mukhopadhyay B. Single layer - vs - two layer closure of
uterus during caesarean section - an institutional experience
[abstract]. XVI FIGO World Congress of Obstetrics &
Gynecology. Book 3; 2000 Sept 3-8; Washington DC,
USA. 2000:43.
Pandey 2006 {published data only}
Pandey R, Kant A. Single layer closure of uterine incision
without closure of visceral and parietal peritonium vs.
double layer closure of uterine incision with visceral and
parietal peritoneal closure - a comparative study. 49th
All India Congress of Obstetrics and Gynaecology; 2006
January 6-9; Cochin, Kerala State, India. 2006:102.
Wojdemann 2010 {published data only}
Wojdemann K, Bennich G. Long term follow-up from a
randomized trial comparing one- and two- layer closure
techniques in caesarean section (cs). Ultrasound in Obstetrics
and Gynecology 2010;36(Suppl 1):141.
References to ongoing studies

Farajzadeh 2010 {published data only}
Farajzadeh F. The comparison of outcomes of traditional
and misgav-ladach techniques in cesarean section. IRCT
Iranian Registry of Clinical Trials (www.irct.ir) (accessed 6
December 2010) (accessed 6 December 2010).
Additional references
ACOG 1999
ACOG Practice Bulletin. Vaginal birth after previous
cesarean delivery. International Journal of Gynecology &
Obstetrics 1999;66:197204.
Bujold 2002
Bujold E, Bujold C, Hamilton EF, Harel F, Gauthier RJ.
The impact of single-layer or double-layer closure on uterine
rupture. American Journal of Obstetrics and Gynecology
2002;186(6):132630.
Chapman 1997
Chapman SJ, Owen J, Hauth JC. One- versus two-later
closure of a low transverse cesarean: the next pregnancy.
Obstetrics & Gynecology 1997;89:168.
Deeks 2001
Deeks JJ, Altman DG, Bradburn MJ. Statistical methods
for examining heterogeneity and combining results from
several studies in meta-analysis. In: Eggar M, Davey Smith
G, Altman DG (eds) editor(s). Systematic Reviews in Health
Care: Meta-analysis in Context. London: BMJ Publishing
Group, 2001.
Higgins 2002
Higgins JPT, Thompson SG. Quantifying heterogeneity in
a meta-analysis. Statistics in Medicine 2002;21:153958.
Higgins 2011
Higgins JPT, Green S, editors. Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 [updated
March 2011]. The Cochrane Collaboration, 2011.
Available from www.cochrane-handbook.org.
Hofmeyr 2008
Hofmeyr GJ, Mathai M, Shah AN, Novikova N.
Techniques for caesarean section. Cochrane Database
of Systematic Reviews 2008, Issue 1. [DOI: 10.1002/
14651858.CD004662.pub2]
RevMan 2012
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.2. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2012.
Tahilramaney 1984
Tahilramaney MP, Boucher M, Eglinton GS, Beall M,
Phelan JP. Previous cesarean section and trial of labor.
Factors related to uterine dehiscence. Journal of Reproductive
Medicine 1984;29(1):1721.
References to other published versions of this review

Dodd 2008
Dodd JM, Anderson ER, Gates S. Surgical techniques for
uterine incision and uterine closure at the time of caesarean
section. Cochrane Database of Systematic Reviews 2008, Issue
3. [DOI: 10.1002/14651858.CD004732.pub2]
Enkin 2006
Enkin MW, Wilkinson C. Single versus two layer suturing
for closing the uterine incision at caesarean section.
Cochrane Database of Systematic Reviews 2006, Issue 3.
[DOI: 10.1002/14651858.CD000192.pub2]
Wilkinson 2006
Wilkinson C, Enkin MW. Absorbable staples for uterine
incision at caesarean section. Cochrane Database of
Systematic Reviews 2006, Issue 3. [DOI: 10.1002/
14651858.CD000005.pub2]
Indicates the major publication for the study
18
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Batioglu 1998
Methods
Method of randomisation: not stated.

Allocation concealment: not stated.
Blinded outcome assessment: not stated.
Completeness of follow-up: outcome data available for 118 women
Participants
118 women undergoing caesarean section. Women with preterm, prelabour ruptured
membranes, chorioamnionitis, or gestational age less than 36 weeks were excluded
Interventions
Single layer uterine closure versus double layer uterine closure
Outcomes
Operating time, duration of hospital stay, postoperative complications, change in haematocrit values
Notes
Trial conducted in Turkey.
Risk of bias
Bias
Authors judgement
Support for judgement
Random sequence generation (selection Unclear risk

bias)
Not stated.
Allocation concealment (selection bias)
Unclear risk
Not stated.
Incomplete outcome data (attrition bias)

All outcomes
Low risk
Outcome data available for 118 women.
Selective reporting (reporting bias)
Low risk
Appears to be free of selective reporting.
Other bias
Low risk
Appears to be free of other bias.
Blinding of participants and personnel Unclear risk

(performance bias)
All outcomes
Not stated.
Blinding of outcome assessment (detection Unclear risk

bias)
All outcomes
Not stated.
19
Bjorklund 2000
Methods
Method of randomisation: computer-generated randomisation sequence.

Allocation concealment: sequential sealed envelopes.
Blinded outcome assessment: no.
Completeness of follow-up: outcome data available for 339 women (1 women excluded
after randomisation)
Participants
340 women undergoing emergency or elective caesarean section. Women with prior
caesarean section, prior abdominal surgery, known anaemia, diabetes mellitus, bleeding
disorder, intrapartum febrile illness, uterine rupture excluded
Interventions
Single layer uterine closure (Misgav Ladach procedure) versus double layer uterine closure
Outcomes
Operating time, blood loss, blood loss greater than 500 mL, Apgar scores, antibiotic use,
postpartum complications, duration hospitalisation
Notes
Trial conducted Dar es Salaam, Tanzania.
Risk of bias
Bias
Authors judgement
Random sequence generation (selection Low risk

bias)
Computer-generated randomisation sequence.
Low risk
Sequential sealed envelopes.

All outcomes
Low risk
Outcome data available for 339 women (1

women excluded after randomisation)
Low risk
Other bias
Low risk
Blinding of participants and personnel High risk

(performance bias)
All outcomes
No blinding of participants and personnel.
Blinding of outcome assessment (detection High risk

bias)
All outcomes
No blinding of outcome assessment.
20
CAESAR 2010
Methods
Method of randomisation: computer-generated randomisation sequence with minimisation algorithm.

Allocation concealment: telephone randomisation service.
Blinded outcome assessment: yes.
Completeness of follow-up: outcome data available for 2979 women (306 women lost
to 6 week follow-up)
Participants
3033 women undergoing primary lower segment caesarean section
Interventions
1. Single versus double layer closure of uterus.

2. Closure versus non-closure of pelvic peritoneum.
3. Liberal versus restricted use of sub-rectus sheath drain.
Outcomes
Infectious morbidity (including wound infection requiring antibiotics, endometritis and

antibiotic use for febrile episode prior to hospital discharge); fever; operating time;
need for blood transfusion; severe maternal morbidity; hospital readmission; operative
procedures on wound
Notes
Trial conducted in 45 sites in United Kingdom and 2 sites in Italy

Primary outcome modified after recruitment of 600 women.
Trial stopped prior to reaching estimated sample size of 3500 women
Risk of bias
Bias
Authors judgement

bias)
Computer-generated randomisation sequence with minimisation algorithm
Low risk
Telephone randomisation service.

All outcomes
Low risk
Outcome data available for 2979 women

(306 women lost to 6 week follow-up)
Low risk
Not apparent.
Other bias
High risk
Primary outcome modified after recruitment of 600 women.

Trial stopped prior to reaching estimated
sample size of 3500 women

(performance bias)
All outcomes
Not stated.
Blinding of outcome assessment (detection Low risk

bias)
All outcomes
Blinded outcome assessment.
21
Ceci 2012
Methods
Randomised trial.
Participants
60 women who were primiparous at term with a singleton pregnancy, delivered by elective
LSCS
Interventions
Uterine closure with continuous locked single layer suture versus interrupted single layer
suture
Outcomes
Ultrasound measures and hysteroscopic assessment of the uterine wall defect if present
at 24 months. No clinical outcomes reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Random number sequence.
Unclear risk
Not specified.

All outcomes
Low risk
Primary outcome data on over 80% of women at 6 months.
Unclear risk
Unclear.
Other bias
Unclear risk
Unclear.

(performance bias)
All outcomes
Not blinded as per the authors.

bias)
All outcomes
Ultrasound and hysteroscopy operators were blinded to the suture technique
Chitra 2004
Methods
Method of randomisation: stated to be randomly allocated by random numbers.

Participants
200 women undergoing primary caesarean section. Women with placenta praevia or
abruption, prior caesarean section, obstructed labour, prior abdominal surgery, multiple
pregnancy or ruptured uterus were excluded
Interventions
Single versus double layer closure of uterus.
22
Chitra 2004
(Continued)
Outcomes
Mean blood loss; operating time.
Notes
Trial conducted in India.
Risk of bias
Bias
Authors judgement

bias)
Stated to be randomly allocated by random numbers.
Unclear risk
Not stated.

All outcomes
Unclear risk
Not stated.
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
CORONIS 2013
Methods
Method of randomisation: computer-generated random number list.

Allocation concealment: secure web-based system.
Blinded outcome assessment: investigators were not blinded? all investigators, surgeons
and participants were unmasked to treatment allocation.
Completeness of follow-up: 6-week data available for 98% of women
Participants
Pregnant women who were to undergo delivery by LSCS through a transverse abdominal
incision, irrespective of fever in labour, gestational age, or multiple pregnancies. Not
eligible if there was a clear indication for a particular surgical technique or material to
be used that prevented any of the allocated interventions being used, if they had more
than one previous caesarean section or if they had already been recruited into the trial
Interventions
5 pairs.
Outcomes
Primary was a maternal composite of death and severe morbidity, plus a range of maternal
and infant outcomes as secondary outcomes
Notes
23
CORONIS 2013
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Central server, computer-generated randomisation list.
Low risk
Central secure web-based system.

All outcomes
Low risk
98% outcome data at 6 weeks (primary

outcome).
Low risk
Other bias
Low risk
No apparent sources of other bias.

(performance bias)
All outcomes
Participants and clinicians and investigators were not blinded

bias)
All outcomes
Unclear who assessed the primary outcome

? investigators or other
Cromi 2008
Methods
Method of randomisation: computer-generated random number list.

Participants
811 women undergoing caesarean section at greater than 30 weeks gestation
Interventions
Transverse versus cephalad-caudad direction of blunt extension of uterine incision
Outcomes
Mean blood loss; need for blood transfusion; operating time.
Notes
Trial conducted in Italy.
Risk of bias
Bias
Authors judgement

bias)
Computer-generated random number list.
Not stated.
Unclear risk
24
Cromi 2008
(Continued)

All outcomes
Low risk
Outcomes available for 811 women.
Low risk
Appears free of selective reporting.
Other bias
Low risk
Appears free of other bias.

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Dani 1998
Methods
Method of randomisation: stated that participants were randomised.

Completeness of follow-up: outcomes reported for 154 infants of women undergoing
caesarean section
Participants
154 infants of women undergoing elective caesarean section after 36 weeks gestation
Interventions
Outcomes
Neonatal respiratory depression, birth asphyxia, cord gases.
Notes
Trial conducted in Italy; no prespecified outcomes reported.
Risk of bias
Bias
Authors judgement

bias)
Stated to be randomised.
Unclear risk
Not stated.

All outcomes
Unclear risk
Outcomes for 154 infants available.
Unclear risk
Unable to assess.
Other bias
Unclear risk
Unable to assess.
25
Dani 1998
(Continued)

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Darj 1999
Methods
Method of randomisation: not stated (participants stated to be randomly allocated).

Completeness of follow-up: outcome data available for 50 women undergoing caesarean
section
Participants
50 women undergoing elective caesarean section at term.
Interventions
Outcomes
Duration surgery, blood loss, doses of analgesics required, duration hospitalisation
Notes
Trial conducted in Sweden.
Risk of bias
Bias
Authors judgement

bias)
Stated to be randomly allocated.
Low risk
Sequential sealed opaque envelopes.

All outcomes
Low risk
Outcome data available for 50 women undergoing caesarean section
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
26
Ferrari 2001
Methods

Completeness of follow-up: outcome data available for 158 women randomised
Participants
158 women undergoing caesarean section at greater than 30 weeks gestation, with no
prior caesarean birth
Interventions
Outcomes
Duration of operation, blood loss, antibiotic use, urinary tract infection, endometritis,
febrile morbidity, postoperative pain score and need for analgesia
Notes
Trial conducted in Italy.
Risk of bias
Bias
Authors judgement

bias)
Not stated.
Low risk
Sequential sealed opaque envelopes.

All outcomes
Low risk
Outcome data available for 158 women

randomised.
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Gutierrez 2008
Methods
Method of randomisation: patients were divided in 2 random groups.

Participants
48 Primigravid women undergoing primary lower segment caesarean section between

37 and 42 weeks gestation
27
Gutierrez 2008
(Continued)
Interventions
Outcomes
Mean blood loss; mean operating time.
Notes
Trial conducted in Mexico.
Risk of bias
Bias
Authors judgement

bias)
Stated that patients were divided in 2 random groups.
Unclear risk
Not stated.

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Hamar 2007
Methods

Completeness of follow-up: outcome data available for 30 women randomised
Participants
30 women undergoing primary caesarean section. Exclusions: multiple gestations, abnormal fetal heart rate tracing, prior uterine surgery, hydramnios, uterine malformation,
diabetes, connective tissue disorder, non-English speaking
Interventions
Outcomes
Chorioamnionitis, endometritis, duration surgery, blood loss, ultrasound assessment of

wound
Notes
Trial conducted in USA.
28
Hamar 2007
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Not stated.
Low risk

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Hauth 1992
Methods
Method of randomisation: computer-generated random-number table.

Completeness of follow-up: 85 women excluded after randomisation (8.6%)
Participants
991 women undergoing caesarean section. Women where vertical or T-incision required,
unable to perform allocated closure, or incomplete data available were excluded
Interventions
Outcomes
Operative time, haemostasis, blood loss, infection, need for haemostatic sutures, endometritis, need for blood transfusion
Notes
Trial conducted USA. Follow-up of 164 women in subsequent pregnancy reported

(Chapman)
Risk of bias
Bias
Authors judgement
29
Hauth 1992
(Continued)

bias)
Computer-generated random number table.
Low risk

All outcomes
Low risk
85 women excluded after randomisation.
Low risk
Other bias
Low risk

(performance bias)
All outcomes
bias)
All outcomes
Hidar 2007
Methods

Allocation concealment: sealed opaque envelopes.
Participants
300 Women undergoing caesarean section after 36 weeks gestation (either elective or
emergency procedure) with a singleton fetus. Women less than 20 years of age, coagulopathy or placenta praevia were excluded
Interventions
Sharp versus blunt extension of the uterine incision.
Outcomes
Endometritis.
Notes
Trial conducted in Tunisia.
Risk of bias
Bias
Authors judgement

bias)
Low risk
Sealed opaque envelopes.

All outcomes
Low risk
30
Hidar 2007
(Continued)
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Lal 1988
Methods
Method of randomisation: allocated randomly (unclear).

Allocation concealment: not stated (unclear).
Completeness of follow-up: outcome data available on 100 women
Participants
100 women undergoing caesarean section for variety of indications
Interventions
Outcomes
Minor and major anomalies of the uterus detected 3 months postpartum by hysterogram
Notes
Trial conducted India.
Risk of bias
Bias
Authors judgement

bias)
Stated to be randomly allocated.
Unclear risk
Not stated.

All outcomes
Unclear risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.
31
Lal 1988
(Continued)

bias)
All outcomes
Not stated.
Magann 2002
Methods

section
Participants
945 women undergoing caesarean section with low transverse uterine incision
Interventions
Blunt dissection of the uterine incision versus sharp dissection of the uterine incision
Outcomes
Blood loss, extension of the incision, need for transfusion, endometritis
Notes
Risk of bias
Bias
Authors judgement

bias)
Computer- generated random number table.
Low risk

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
bias)
All outcomes
32
Moreira 2002
Methods
Method of randomisation: not described.

Allocation concealment: not described.
Blinded outcome assessment: not indicated.
section
Participants
400 women undergoing caesarean section.
Interventions
Outcomes
Endometritis.
Notes
Trial conducted in Senegal.
Risk of bias
Bias
Authors judgement

bias)
Not stated.
Unclear risk
Not stated.

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Poonam 2006
Methods
Method of randomisation: stated to be randomised.

Participants
400 Women undergoing primary lower segment caesarean section at greater than 37
weeks gestation
33
Poonam 2006
(Continued)
Interventions
1. Blunt versus sharp dissection uterine incision.

2. Single versus double layer closure of uterus.
Outcomes
Infectious morbidity; blood loss; need for blood transfusion; maternal death or serious
morbidity
Notes
Trial conducted in Nepal.
Risk of bias
Bias
Authors judgement

bias)
Unclear risk
Not stated.

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Rodriguez 1994
Methods

section
Participants
296 women undergoing caesarean section. Women excluded if there was insufficient
time to provide consent or due to time restraints due to an emergency procedure
Interventions
Blunt dissection of the uterine incision versus sharp dissection of the uterine incision
Outcomes
Change in haemoglobin, delivery time, extension of the incision, damage to blood vessels,
endometritis
34
Rodriguez 1994
(Continued)
Notes
Risk of bias
Bias
Authors judgement

bias)
Not stated.
Unclear risk
Not stated.

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Sekhavat 2010
Methods

Participants
200 primiparous women undergoing caesarean section at term. Women with multiple
pregnancy, major medical or surgical conditions, anaemia, thromboembolic disease,
polyhydramnios or requiring emergency caesarean section were excluded
Interventions
Outcomes
Operating time; blood loss; need for blood transfusion.
Notes
Trial conducted in Iran.
Risk of bias
Bias
Authors judgement
35
Sekhavat 2010
(Continued)

bias)
Low risk

All outcomes
Low risk
Low risk
Other bias
Low risk
Blinding of participants and personnel Low risk

(performance bias)
All outcomes
Participants blinded.

bias)
All outcomes
Not stated.
Sood 2005
Methods

Participants
Interventions
Outcomes
Data presented not able to be used.
Notes
Trial conducted in India.
Risk of bias
Bias
Authors judgement

bias)
Low risk

All outcomes
Low risk
Outcomes for 208 women.
36
Sood 2005
(Continued)
Unclear risk
Unable to assess.
Other bias
Unclear risk
Unable to assess.

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Outcome assessor blinded.
Studzinski 2002
Methods

Participants
Interventions
Outcomes
Infectious morbidity operating time; blood loss.
Notes
Trial conducted in Poland.
Risk of bias
Bias
Authors judgement

bias)
Not stated.
Unclear risk
Not stated.

All outcomes
Low risk
Outcome data for 110 women.
Unclear risk
Unable to assess.
Other bias
Unclear risk
Unable to assess.

(performance bias)
All outcomes
Not stated.
37
Studzinski 2002
(Continued)

bias)
All outcomes
Not stated.
Villeneuve 1990
Methods
Method of randomisation: random-number table.

section
Participants
200 women undergoing lower uterine segment caesarean section
Interventions
Auto suture device versus standard hysterotomy.
Outcomes
Operating time, blood loss, change in haemoglobin, febrile morbidity, postoperative

complications, length of hospitalisation
Notes
Trial conducted in Canada.
Risk of bias
Bias
Authors judgement

bias)
Random number table.
Low risk

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
bias)
All outcomes
38
Von Rechenberg 1990

Methods
Method of randomisation: randomised - no further information provided.

Allocation concealment: no information provided.
Blinded outcome assessment: no information provided.
Completeness of follow-up: no exclusions reported.
Participants
100 women undergoing caesarean section. Exclusions: clotting dysfunction, multiple

pregnancy, delivery less than 32 weeks
Interventions
Auto suture device versus conventional incision (no further information provided)
Outcomes
Blood loss, transfusion, wound haematoma (US assessed), febrile morbidity, antibiotic
use, endometritis, duration of hospital stay
Notes
Trial conducted in Switzerland.
Risk of bias
Bias
Authors judgement

bias)
Unclear risk
Not stated.

All outcomes
Low risk
Data available for 100 women.
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Not stated.
Wallin 1999
Methods

section
39
Wallin 1999
(Continued)
Participants
72 women undergoing elective caesarean section in the absence of a history of prior

abdominal surgery
Interventions
Outcomes
Median operating time, blood loss, length of hospitalisation
Notes
Trial conducted in Sweden.
Risk of bias
Bias
Authors judgement

bias)
Low risk

All outcomes
Low risk
Low risk
Other bias
Low risk

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Outcome assessor blinded.
Xavier 2005
Methods

Allocation concealment: unclear.
section
Participants
162 women undergoing caesarean section by 1 of 3 operating surgeons
Interventions
Outcomes
Wound infection, febrile morbidity requiring antibiotics.
40
Xavier 2005
(Continued)
Notes
Trial conducted in Portugal.
Risk of bias
Bias
Authors judgement

bias)
Unclear risk
Not stated.

All outcomes
Low risk
Outcomes available for 72 of 162 women

randomised.
Low risk
Other bias
High risk
Data available for 44.4% of women randomised.

(performance bias)
All outcomes
Not stated.

bias)
All outcomes
Blinding of outcomes assessment.
Yasmin 2011
Methods
A randomised double blind trial.
Participants
Singleton, term pregnancies, scheduled for repeat elective caesarean section
Interventions
Group A - 1 layer closure, Group B - 2 layer closure, Group C - modified 2 layer closure
Outcomes
Blood loss, operating time and ultrasound findings at 6 weeks and at time of next
caesarean section
Notes
Risk of bias
Bias
Authors judgement
Random sequence generation (selection High risk

bias)
Random allocation made using cards, patient picked

cards from a box
Allocation not concealed after generated, see above.
High risk
41
Yasmin 2011
(Continued)

All outcomes
High risk
Only approximately 50% of patients followed at

time of next caesarean section which was one of the
main aims of the study
Low risk
None apparent.
Other bias
Low risk
None apparent.

(performance bias)
All outcomes
States double blind trial, but not entirely clear,

The group allocation was revealed to the surgeon
during the surgery just before the uterine incision
closure, not clear if or participants were blinded

bias)
All outcomes
Some blinding of outcome assessors. Postoperative

evaluation of uterine incision, Measurements were
done by one of the investigators who were blinded
to the allocation group for type of closure
LSCS: lower segment caesarean section

US: ultrasound
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Ansaloni 2001
Study used quasi-randomised allocation to the intervention based on alternate allocation
Baxter 2008
The comparison did not involve techniques on the uterus and was outside the scope of this review
Behrens 1997
Buhimschi 2006
Dargent 1990
Study used quasi-randomised allocation based on mothers month of birth
Decavalas 1997
Doganay 2010
Falls 1958
Gaucherand 2001
Study used quasi-randomised allocation to the intervention based on odd/even date of surgery
42
(Continued)
Gedikbasi 2011
Ghezzi 2001
Giacalone 2002
Excluded as the comparison involved Maylard versus Pfannensteil procedure for caesarean section. The Maylard
procedure describes entry into the abdominal cavity, prior to entry of the uterine cavity. The comparison did
not involve techniques on the uterus and was outside the scope of this review
Hameed 2004
Study used a convenient sampling method to allocate treatment groups
Heidenreich 1995
Heimann 2000
Analysis was not based on intention-to-treat principles and it was not possible to restore participants to their
randomised intervention from the results presented
Hohlagschwandtner
Excluded as the comparison involved bladder dissection prior to uterine entry versus no bladder dissection.
Hoskins 1991
Study used quasi-randomised allocation to the intervention based on odd or even allocation using medical
record number
Kiefer 2008
Lodh 2002
Study utilised a case-control design and was not randomised.
Malvasi 2011
Moroz 2008
Naki 2011
Ohel 1996
Study used quasi-randomised allocation to the intervention based on odd or even allocation using medical
record number
Ozbay 2011
Redlich 2001
Study used quasi-randomised allocation to the intervention based on patient surname
Van Dongen 1989
43
Characteristics of studies awaiting assessment [ordered by study ID]

Belci 2005
Methods
Participants
Interventions
Outcomes
Notes
Polish - needs translation.
Borowski 2007
Methods
Participants
Interventions
Outcomes
Notes
In abstract form only, with insufficient information available to allow assessment for inclusion in this review
Hagen 1999
Methods
Participants
Interventions
Outcomes
Notes
Mazhar 2004
Methods
Participants
Interventions
Outcomes
Notes
44
Mukhopadhyay 2000
Methods
Participants
Interventions
Outcomes
Notes
Pandey 2006
Methods
Participants
Interventions
Outcomes
Notes
Wojdemann 2010
Methods
Participants
Interventions
Outcomes
Notes
Characteristics of ongoing studies [ordered by study ID]

Farajzadeh 2010
Trial name or title
The comparison of outcomes of traditional and misgav-ladach techniques in cesarean section
Methods
Participants
Interventions
Outcomes
45
Farajzadeh 2010
(Continued)
Starting date
Contact information
IRCT Iranian Registry of Clinical Trials (www.irct.ir) (accessed 6 December 2010)
Notes
46
DATA AND ANALYSES
Comparison 1. Methods of performing the uterine incision: auto stapler versus conventional
No. of
studies
No. of
participants
1 Febrile morbidity
2 Mean blood loss
2
1
300
200
Risk Ratio (M-H, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)
3 Duration of surgery
4 Duration of postnatal stay
5 Wound complications
6 Need for blood transfusion
7 Endometritis
1
1
1
1
1
197
200
100
100
100

Outcome or subgroup title
Statistical method
Effect size
0.92 [0.38, 2.20]
-87.0 [-175.09, 1.
09]
3.30 [-0.02, 6.62]
0.0 [-0.28, 0.28]
1.5 [0.67, 3.35]
1.5 [0.26, 8.60]
0.2 [0.02, 1.65]
Comparison 2. Methods of performing the uterine incision: blunt versus sharp dissection
No. of
studies
No. of
participants
1 Postoperative febrile morbidity

(including endometritis)
2 Mean blood loss
1941
0.86 [0.70, 1.05]
1145
Mean Difference (IV, Random, 95% CI)

4 Maternal death or serious
morbidity
2
1
1345
400

-53.00 [-79.48, -30.

52]
0.24 [0.09, 0.62]
3.0 [0.12, 73.20]
200
-2.80 [-5.84, 0.24]
Statistical method
Effect size
Comparison 3. Methods of performing the uterine incision: transverse versus cephalad-caudad blunt extension
No. of
studies
No. of
participants
1 Mean blood loss

1
1
1
811
811
811
Statistical method
Effect size
42.0 [1.31, 82.69]
1.00 [0.20, 4.91]
-1.50 [-3.13, 0.13]
47
Comparison 4. Single layer uterine closure versus double layer uterine closure

2 Blood loss greater than 500 mL
4 Wound infection
5 Operative procedure on wound
6 Postoperative anaemia
7 Complication of future
pregnancy
8 Postoperative pain present
9 Complications post-op requiring
re-laparotomy
10 Length of hospital stay
11 Death or serious maternal
morbidity
12 Maternal readmission
No. of
studies
No. of
participants
13890
0.98 [0.85, 1.12]
1
4
5
3
2
1
339
13571
13389
12604
1245
145

Risk Ratio (M-H, Random, 95% CI)
0.70 [0.42, 1.18]

0.86 [0.63, 1.17]
0.99 [0.89, 1.10]
0.80 [0.53, 1.21]
1.05 [0.83, 1.32]
3.21 [0.13, 77.55]
2
1
9444
9286
Risk Ratio (M-H, Random, 95% CI)

0.88 [0.54, 1.42]

0.85 [0.63, 1.16]
1
3
158
12665

-0.10 [-0.52, 0.32]

1.04 [0.71, 1.54]
9286
1.12 [0.70, 1.79]
Statistical method
Effect size
Comparison 5. Techniques for closing the uterus: chromic catgut versus polygactin-910

3 Wound infection
4 Operative procedure on wound
5 Postoperative pain present
6 Complications post-op requiring
re-laparotomy
7 Death or serious maternal
morbidity
8 Maternal readmission
No. of
studies
No. of
participants
9544
0.70 [0.49, 1.00]
1
1
1
1
1
9544
9544
9544
9544
9544

0.49 [0.32, 0.76]

0.99 [0.82, 1.19]
0.64 [0.36, 1.13]
0.86 [0.70, 1.07]
0.58 [0.37, 0.89]
9544
0.68 [0.44, 1.06]
9544
1.00 [0.58, 1.72]
Statistical method
Effect size
48
Analysis 1.1. Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional,
Outcome 1 Febrile morbidity.
Review:
Surgical techniques for uterine incision and uterine closure at the time of caesarean section
Comparison: 1 Methods of performing the uterine incision: auto stapler versus conventional
Outcome: 1 Febrile morbidity
Study or subgroup
Stapler
Conventional
n/N
n/N
Villeneuve 1990
4/98
6/102
59.5 %
0.69 [ 0.20, 2.38 ]
Von Rechenberg 1990
5/50
4/50
40.5 %
1.25 [ 0.36, 4.38 ]
148
152
100.0 %
0.92 [ 0.38, 2.20 ]
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 9 (Stapler), 10 (Conventional)

Heterogeneity: Chi2 = 0.43, df = 1 (P = 0.51); I2 =0.0%
Test for overall effect: Z = 0.19 (P = 0.85)
Test for subgroup differences: Not applicable
0.1 0.2
0.5
Favours stapler
10
Favours conventional
Outcome 2 Mean blood loss.
Review:
Outcome: 2 Mean blood loss
Study or subgroup
Villeneuve 1990
Total (95% CI)
Stapler
Mean
Difference
Conventional
Mean(SD)
Mean(SD)
98
492 (237.6)
102
579 (383.8)
98
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
102
100.0 %
-87.00 [ -175.09, 1.09 ]
100.0 %
-87.00 [ -175.09, 1.09 ]
Heterogeneity: not applicable

-100
-50
Favours stapler
50
100
49
Outcome 3 Duration of surgery.
Review:
Outcome: 3 Duration of surgery
Study or subgroup
Villeneuve 1990
Total (95% CI)
Stapler
Mean
Difference
Conventional
Mean(SD)
Mean(SD)
97
42.5 (11.8)
100
39.2 (12)
97
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
100
100.0 %
3.30 [ -0.02, 6.62 ]
100.0 %
3.30 [ -0.02, 6.62 ]

-10
-5
Favours stapler
10
Outcome 4 Duration of postnatal stay.
Review:
Outcome: 4 Duration of postnatal stay
Mean
Difference
Study or subgroup
Stapler
N
Mean(SD)
Mean(SD)
Villeneuve 1990
98
6.3 (0.99)
102
6.3 (1.01)
Total (95% CI)
Conventional
98
Weight
Mean
Difference
100.0 %
0.0 [ -0.28, 0.28 ]
100.0 %
0.0 [ -0.28, 0.28 ]
IV,Fixed,95% CI
IV,Fixed,95% CI
102

-10
-5
Favours stapler
10
50
Outcome 5 Wound complications.
Review:
Outcome: 5 Wound complications
Study or subgroup
Von Rechenberg 1990
Total (95% CI)
Stapler
Conventional
n/N
n/N
Risk Ratio
Weight
12/50
8/50
100.0 %
1.50 [ 0.67, 3.35 ]
50
50
100.0 %
1.50 [ 0.67, 3.35 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.1 0.2
0.5
Favours stapler
10
Outcome 6 Need for blood transfusion.
Review:
Outcome: 6 Need for blood transfusion
Study or subgroup
Von Rechenberg 1990
Total (95% CI)
Stapler
Conventional
n/N
n/N
Risk Ratio
Weight
3/50
2/50
100.0 %
1.50 [ 0.26, 8.60 ]
50
50
100.0 %
1.50 [ 0.26, 8.60 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.1 0.2
0.5
Favours stapler
10
51
Outcome 7 Endometritis.
Review:
Outcome: 7 Endometritis
Study or subgroup
Von Rechenberg 1990
Total (95% CI)
Stapler
Conventional
n/N
n/N
Risk Ratio
Weight
1/50
5/50
100.0 %
0.20 [ 0.02, 1.65 ]
50
50
100.0 %
0.20 [ 0.02, 1.65 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.02
0.1
10
Favours stapler
50
Analysis 2.1. Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection,
Outcome 1 Postoperative febrile morbidity (including endometritis).
Review:
Comparison: 2 Methods of performing the uterine incision: blunt versus sharp dissection
Outcome: 1 Postoperative febrile morbidity (including endometritis)
Study or subgroup
Blunt extension
Sharp extension
n/N
n/N
3/147
2/153
1.3 %
1.56 [ 0.26, 9.21 ]
Magann 2002
51/475
66/470
45.4 %
0.76 [ 0.54, 1.08 ]
Poonam 2006
7/200
14/200
9.6 %
0.50 [ 0.21, 1.21 ]
63/145
65/151
43.6 %
1.01 [ 0.78, 1.31 ]
967
974
100.0 %
0.86 [ 0.70, 1.05 ]
Hidar 2007
Rodriguez 1994
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 124 (Blunt extension), 147 (Sharp extension)

Heterogeneity: Chi2 = 3.80, df = 3 (P = 0.28); I2 =21%
0.1 0.2
0.5
Favours blunt
10
Favours sharp
52
Outcome 2 Mean blood loss.
Review:
Study or subgroup
Blunt
Mean
Difference
Sharp
Weight
IV,Random,95% CI
Mean
Difference
Mean(SD)
Mean(SD)
IV,Random,95% CI
Magann 2002
475
843 (164)
470
886 (197)
52.0 %
-43.00 [ -66.12, -19.88 ]
Sekhavat 2010
100
375 (95)
100
443 (86)
48.0 %
-68.00 [ -93.12, -42.88 ]
Total (95% CI)
575
100.0 %
-55.00 [ -79.48, -30.52 ]
570
Heterogeneity: Tau2 = 160.80; Chi2 = 2.06, df = 1 (P = 0.15); I2 =51%

-50
-25
Favours blunt
25
50
Favours sharp
53
Review:
Study or subgroup
Blunt
Sharp
n/N
n/N
Risk Ratio
Weight
Magann 2002
2/475
9/470
43.0 %
0.22 [ 0.05, 1.01 ]
Poonam 2006
3/200
12/200
57.0 %
0.25 [ 0.07, 0.87 ]
Total (95% CI)
675
670
100.0 %
0.24 [ 0.09, 0.62 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 5 (Blunt), 21 (Sharp)

0.05
0.2
Favours blunt
20
Favours sharp
Outcome 4 Maternal death or serious morbidity.
Review:
Outcome: 4 Maternal death or serious morbidity
Study or subgroup
Blunt Dissection
Sharp Dissection
n/N
n/N
Risk Ratio
Weight
Poonam 2006
1/200
0/200
100.0 %
3.00 [ 0.12, 73.20 ]
Total (95% CI)
200
200
100.0 %
3.00 [ 0.12, 73.20 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 1 (Blunt Dissection), 0 (Sharp Dissection)

0.01
0.1
Favours blunt
10
100
Favours sharp
54
Outcome 5 Duration of surgery.
Review:
Study or subgroup
Blunt Dissection
Mean
Difference
Sharp Dissection
Mean(SD)
Mean(SD)
Sekhavat 2010
100
27.9 (10.5)
100
30.7 (11.4)
Total (95% CI)
100
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
100.0 %
100
-2.80 [ -5.84, 0.24 ]
100.0 % -2.80 [ -5.84, 0.24 ]

-100
-50
Favours blunt
50
100
Favours sharp
Analysis 3.1. Comparison 3 Methods of performing the uterine incision: transverse versus cephalad-caudad
blunt extension, Outcome 1 Mean blood loss.
Review:
Comparison: 3 Methods of performing the uterine incision: transverse versus cephalad-caudad blunt extension
Study or subgroup
Cephaladcaudad
extension
Transverse extension
Cromi 2008
Total (95% CI)
Mean
Difference
Mean(SD)
Mean(SD)
406
440 (341)
405
398 (242)
406
Weight
Mean
Difference
100.0 %
42.00 [ 1.31, 82.69 ]
IV,Fixed,95% CI
IV,Fixed,95% CI
100.0 % 42.00 [ 1.31, 82.69 ]
405

-100
-50
Favours transverse
50
100
Favours cephalad
55
blunt extension, Outcome 2 Need for blood transfusion.
Review:
Study or subgroup
Cephaladcaudad
extension
n/N
n/N
3/406
3/405
100.0 %
1.00 [ 0.20, 4.91 ]
406
405
100.0 %
1.00 [ 0.20, 4.91 ]
Cromi 2008
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 3 (Transverse extension), 3 (Cephalad-caudad extension)

0.01
0.1
Favours transverse
10
100
Favours cephalad
blunt extension, Outcome 3 Duration of surgery.
Review:
Study or subgroup
Cephaladcaudad
extension
Cromi 2008
Total (95% CI)
Mean
Difference
Mean(SD)
Mean(SD)
406
38.9 (11.9)
405
40.4 (11.8)
406
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
100.0 %
405
-1.50 [ -3.13, 0.13 ]
100.0 % -1.50 [ -3.13, 0.13 ]

-100
-50
Favours transverse
50
100
Favours cephalad
56
Analysis 4.1. Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 1
Postoperative febrile morbidity (including endometritis).
Review:
Comparison: 4 Single layer uterine closure versus double layer uterine closure
Study or subgroup
Single layer closure
Double layer closure
n/N
n/N
Bjorklund 2000
22/169
16/170
4.5 %
1.38 [ 0.75, 2.54 ]
CAESAR 2010
247/1483
249/1496
70.2 %
1.00 [ 0.85, 1.18 ]
47/4639
47/4647
13.3 %
1.00 [ 0.67, 1.50 ]
Ferrari 2001
10/83
13/75
3.9 %
0.70 [ 0.32, 1.49 ]
Moreira 2002
5/200
2/200
0.6 %
2.50 [ 0.49, 12.74 ]
Poonam 2006
7/200
14/200
4.0 %
0.50 [ 0.21, 1.21 ]
Studzinski 2002
3/50
8/60
2.1 %
0.45 [ 0.13, 1.61 ]
Wallin 1999
2/36
1/36
0.3 %
2.00 [ 0.19, 21.09 ]
Xavier 2005
1/77
4/69
1.2 %
0.22 [ 0.03, 1.96 ]
6937
6953
100.0 %
0.98 [ 0.85, 1.12 ]
CORONIS 2013
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 344 (Single layer closure), 354 (Double layer closure)
0.5
0.7
Favours single layer
1.5
Favours double layer
57
Blood loss greater than 500 mL.
Review:
Outcome: 2 Blood loss greater than 500 mL
Study or subgroup
n/N
n/N
21/169
30/170
100.0 %
0.70 [ 0.42, 1.18 ]
169
170
100.0 %
0.70 [ 0.42, 1.18 ]
Bjorklund 2000
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.1 0.2
0.5
10
Need for blood transfusion.
Review:
Study or subgroup
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
CAESAR 2010
54/1483
59/1496
38.7 %
0.92 [ 0.64, 1.33 ]
CORONIS 2013
76/4639
79/4647
44.8 %
0.96 [ 0.71, 1.32 ]
Hauth 1992
9/457
11/449
10.9 %
0.80 [ 0.34, 1.92 ]
Poonam 2006
3/200
12/200
5.7 %
0.25 [ 0.07, 0.87 ]
Total (95% CI)
6779
6792
100.0 %
0.86 [ 0.63, 1.17 ]
0.1 0.2
0.5
10
58
Wound infection.
Review:
Outcome: 4 Wound infection
Study or subgroup
n/N
n/N
CAESAR 2010
188/1483
188/1496
29.5 %
1.01 [ 0.84, 1.22 ]
CORONIS 2013
353/4639
379/4647
59.7 %
0.93 [ 0.81, 1.07 ]
Hauth 1992
83/457
65/449
10.3 %
1.25 [ 0.93, 1.69 ]
Wallin 1999
1/36
1/36
0.2 %
1.00 [ 0.07, 15.38 ]
Xavier 2005
4/77
2/69
0.3 %
1.79 [ 0.34, 9.48 ]
6692
6697
100.0 %
0.99 [ 0.89, 1.10 ]
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
0.05
0.2
20
59
Operative procedure on wound.
Review:
Outcome: 5 Operative procedure on wound
Study or subgroup
n/N
n/N
Risk Ratio
Weight
Bjorklund 2000
1/169
3/170
6.0 %
0.34 [ 0.04, 3.19 ]
CAESAR 2010
9/1483
9/1496
18.0 %
1.01 [ 0.40, 2.53 ]
CORONIS 2013
30/4639
38/4647
76.1 %
0.79 [ 0.49, 1.27 ]
Total (95% CI)
6291
6313
100.0 %
0.80 [ 0.53, 1.21 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.05
0.2
20
60
Postoperative anaemia.
Review:
Outcome: 6 Postoperative anaemia
Study or subgroup
n/N
n/N
6/169
10/170
8.9 %
0.60 [ 0.22, 1.62 ]
112/457
101/449
91.1 %
1.09 [ 0.86, 1.38 ]
626
619
100.0 %
1.05 [ 0.83, 1.32 ]
Bjorklund 2000
Hauth 1992
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
0.1 0.2
0.5
10
Complication of future pregnancy.
Review:
Outcome: 7 Complication of future pregnancy
Study or subgroup
n/N
n/N
1/70
0/75
100.0 %
3.21 [ 0.13, 77.55 ]
70
75
100.0 %
3.21 [ 0.13, 77.55 ]
Hauth 1992
Total (95% CI)
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
10
100
61
Postoperative pain present.
Review:
Outcome: 8 Postoperative pain present
Study or subgroup

n/N
n/N
CORONIS 2013
203/4639
185/4647
52.3 %
1.10 [ 0.90, 1.34 ]
38/83
50/75
47.7 %
0.69 [ 0.52, 0.91 ]
4722
4722
100.0 %
0.88 [ 0.54, 1.42 ]
Ferrari 2001
Total (95% CI)
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
0.1 0.2
0.5
10
62
Complications post-op requiring re-laparotomy.
Review:
Outcome: 9 Complications post-op requiring re-laparotomy
Study or subgroup
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
74/4639
87/4647
100.0 %
0.85 [ 0.63, 1.16 ]
Total (95% CI)
4639
4647
100.0 %
0.85 [ 0.63, 1.16 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
10
100
Length of hospital stay.
Review:
Outcome: 10 Length of hospital stay
Study or subgroup Single layer closure
Ferrari 2001
Total (95% CI)
Mean
Difference
Mean(SD)
Mean(SD)
83
4.8 (1.37)
75
4.9 (1.3)
83
Weight
Mean
Difference
100.0 %
-0.10 [ -0.52, 0.32 ]
IV,Fixed,95% CI
IV,Fixed,95% CI
75
100.0 % -0.10 [ -0.52, 0.32 ]

-10
-5
10
63
Death or serious maternal morbidity.
Review:
Outcome: 11 Death or serious maternal morbidity
Study or subgroup
n/N
n/N
7/1483
11/1496
22.2 %
0.64 [ 0.25, 1.65 ]
43/4639
38/4647
76.8 %
1.13 [ 0.73, 1.75 ]
Poonam 2006
1/200
0/200
1.0 %
3.00 [ 0.12, 73.20 ]
Total (95% CI)
6322
6343
100.0 %
1.04 [ 0.71, 1.54 ]
CAESAR 2010
CORONIS 2013
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
10
100
Maternal readmission.
Review:
Outcome: 12 Maternal readmission
Study or subgroup
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
37/4639
33/4647
100.0 %
1.12 [ 0.70, 1.79 ]
Total (95% CI)
4639
4647
100.0 %
1.12 [ 0.70, 1.79 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
10
100
64
Analysis 5.1. Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin-910,
Outcome 1 Postoperative febrile morbidity (including endometritis).
Review:
Comparison: 5 Techniques for closing the uterus: chromic catgut versus polygactin-910
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
52/4954
69/4590
100.0 %
0.70 [ 0.49, 1.00 ]
Total (95% CI)
4954
4590
100.0 %
0.70 [ 0.49, 1.00 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 52 (Catgut), 69 (Polygactin)

0.5
0.7
Catgut
1.5
Polygactin
65
Review:
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
32/4954
60/4590
100.0 %
0.49 [ 0.32, 0.76 ]
Total (95% CI)
4954
4590
100.0 %
0.49 [ 0.32, 0.76 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.1 0.2
0.5
Favours catgut
10
Favours polygactin
Outcome 3 Wound infection.
Review:
Outcome: 3 Wound infection
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
218/4954
204/4590
100.0 %
0.99 [ 0.82, 1.19 ]
Total (95% CI)
4954
4590
100.0 %
0.99 [ 0.82, 1.19 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.05
0.2
Favours catgut
20
Favours polygactin
66
Outcome 4 Operative procedure on wound.
Review:
Outcome: 4 Operative procedure on wound
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
20/4954
29/4590
100.0 %
0.64 [ 0.36, 1.13 ]
Total (95% CI)
4954
4590
100.0 %
0.64 [ 0.36, 1.13 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.05
0.2
Favours catgut
20
Favours polygactin
Outcome 5 Postoperative pain present.
Review:
Outcome: 5 Postoperative pain present
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
159/4954
171/4590
100.0 %
0.86 [ 0.70, 1.07 ]
Total (95% CI)
4954
4590
100.0 %
0.86 [ 0.70, 1.07 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.1 0.2
0.5
Favours catgut
10
Favours polygactin
67
Outcome 6 Complications post-op requiring re-laparotomy.
Review:
Outcome: 6 Complications post-op requiring re-laparotomy
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
33/4954
53/4590
100.0 %
0.58 [ 0.37, 0.89 ]
Total (95% CI)
4954
4590
100.0 %
0.58 [ 0.37, 0.89 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours catgut
10
100
Favours polygactin
Outcome 7 Death or serious maternal morbidity.
Review:
Outcome: 7 Death or serious maternal morbidity
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
CORONIS 2013
34/4954
46/4590
100.0 %
0.68 [ 0.44, 1.06 ]
Total (95% CI)
4954
4590
100.0 %
0.68 [ 0.44, 1.06 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours catgut
10
100
Favours polygactin
68
Outcome 8 Maternal readmission.
Review:
Outcome: 8 Maternal readmission
Study or subgroup
Catgut
Polygactin
n/N
n/N
Risk Ratio
Weight
Risk Ratio
CORONIS 2013
27/4954
25/4590
100.0 %
1.00 [ 0.58, 1.72 ]
Total (95% CI)
4954
4590
100.0 %
1.00 [ 0.58, 1.72 ]
M-H,Fixed,95% CI
M-H,Fixed,95% CI

0.01
0.1
10
100
APPENDICES
Appendix 1. Methods used to assess trials included in previous versions of this review
The following methods were used to assess Batioglu 1998; Bjorklund 2000; Dani 1998; Darj 1999; Ferrari 2001; Hamar 2007; Hauth
1992; Lal 1988; Magann 2002; Moreira 2002; Rodriguez 1994; Villeneuve 1990; Von Rechenberg 1990; Wallin 1999; Xavier 2005.
Two authors evaluated trials under consideration for appropriateness for inclusion and methodological quality without consideration
of their results according to the prestated eligibility criteria.
We assessed trials that met the eligibility criteria for quality using the following criteria:
1. generation of random allocation sequence: adequate, inadequate, unclear;
2. allocation concealment: A = adequate, B = unclear, C = inadequate;
3. blinding of participants: yes, no, inadequate, no information;
4. blinding of caregivers: yes, no, inadequate, no information;
5. blinding of outcome assessment: yes, no, inadequate, no information;
6. completeness of follow-up data (including any differential loss of participants from each group): (a) less than 3% of participants
excluded; (b) 3% to 9.9% of participants excluded; (c) 10% to 19.9% of participants excluded; (d) 20% or more excluded; and (e)
unclear;
7. analysis of participants in randomised groups.
Two authors extracted data independently. We resolved differences of opinion by discussion or referral to the primary editor. We
included in the Studies awaiting classification category studies reported only in abstract form that contained insufficient detail to allow
assessment of their eligibility or methods. They will be included in the analyses when published as full reports.
We combined data from different trials if they were sufficiently similar for this to be reasonable in the judgement of the authors.
We performed meta-analyses using risk ratios as the measure of effect size for binary outcomes, and mean differences for continuous
outcome measures.
69
We used fixed-effect meta-analysis for combining study data where the trials were judged to be sufficiently similar. We investigated
heterogeneity by calculating statistics (Higgins 2002), and if this indicated a high level of heterogeneity among the trials included in an
analysis, we used random-effects meta-analysis for an overall summary. We explored high levels of heterogeneity, where found, by the
prespecified subgroup analyses and by sensitivity analyses excluding trials most susceptible to bias based on the quality assessment: those
with inadequate allocation concealment; high levels of postrandomisation losses or exclusions; or unblinded outcome assessment, or
blinding of outcome assessment uncertain. However, this was not conducted due to the number of trials included in the meta-analysis.
Planned subgroup analyses were:
1. first versus repeat caesarean versus mixed/undefined;
2. prelabour versus intrapartum caesarean versus mixed/undefined;
3. preterm versus term caesarean versus mixed/undefined;
4. general versus regional anaesthesia versus mixed/undefined.
We investigated heterogeneity to assess the differences between the subgroups using the methods described by Deeks 2001.
WHATS NEW
Last assessed as up-to-date: 1 September 2013.
Date
Event
Description
1 September 2013
New citation required and conclusions have changed
Twelve new trials included (CAESAR 2010; Ceci 2012;

Chitra 2004; CORONIS 2013; Cromi 2008; Gutierrez
2008; Hidar 2007; Poonam 2006; Sekhavat 2010; Sood
2005; Studzinski 2002; Yasmin 2011). For the comparison, blunt versus sharp dissection when performing the
uterine incision, there is now additional evidence from
one study to suggest a significant reduction in the need
for blood transfusion with blunt extension
1 September 2013
New search has been performed
Search updated and 30 trial reports identified.
HISTORY
Protocol first published: Issue 2, 2004
Review first published: Issue 3, 2008
Date
Event
Description
27 June 2012
Amended
Search updated. Twenty-three reports added to Studies awaiting classification.
23 January 2008
Amended
Converted to new review format
70
CONTRIBUTIONS OF AUTHORS
J Dodd drafted the original version of the protocol. J Dodd, E Anderson and S Gates were all involved in the development of the review,
including identification of studies, assessment for eligibility, data extraction and revision for content. J Dodd and R Grivell conducted
the assessment of studies and data extraction for the review update, and J Dodd and R Grivell drafted the text for the review update.
All authors contributed to revision for content.
DECLARATIONS OF INTEREST
S Gates and E Anderson are both involved in the CAESAR trial comparing single with double layer uterine closure.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

The title of the protocol was Surgical techniques for uterine closure involving the uterus at the time of caesarean section. We have changed
the title of the review in response to feedback from reviewers. Methods updated.
INDEX TERMS
Medical Subject Headings (MeSH)
Suture
Techniques [instrumentation]; Abdominal Wound Closure Techniques; Blood Loss, Surgical; Cesarean Section [ methods];
Dissection [ methods]; Randomized Controlled Trials as Topic; Sutures; Time Factors
MeSH check words

Female; Humans; Pregnancy
71

Surgical Techniques For Uterine Incision and Uterine Closure at

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Surgical Techniques For Uterine Incision and Uterine Closure at

Загружено:

Авторское право:

Доступные форматы

Surgical techniques for uterine incision and uterine closure at

the time of caesarean section (Review)

Surgical techniques for uterine incision and uterine closure at

PLAIN LANGUAGE SUMMARY

Description of the condition

Description of the intervention

How the intervention might work

Part one: type of uterine incision at caesarean section

are also associated with a lower incidence of uterine dehiscence or

a scalpel and then extended laterally with scissors (sharp uterine

women. However, a recent observational study from Canada has

Why it is important to do this review

Criteria for considering studies for this review

Types of outcome measures

Outcome measures for the infant (applicable to part one and

Health service use

Postoperative febrile morbidity (as defined by trial authors).

Search methods for identification of studies

Outcome measures for the woman

We searched the Cochrane Pregnancy and Childbirth Groups

Longer-term outcome measures for the woman

Searching other resources

Data collection and analysis

We described for each included study the method used to generate

low risk of bias (e.g. telephone or central randomisation;

(3.1) Blinding of participants and personnel (checking for

We described for each included study the methods used, if any, to

(3.2) Blinding of outcome assessment (checking for possible

We described for each included study the methods used, if any, to

(4) Incomplete outcome data (checking for possible attrition

We described for each included study, and for each outcome or

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the

(6) Other bias (checking for bias due to problems not

We described for each included study any important concerns we

(7) Overall risk of bias

We made explicit judgements about whether studies were at high

Unit of analysis issues

We planned to include cluster-randomised trials in the analyses

Dealing with missing data

For dichotomous data, we presented results as summary risk ratio

For included studies, we noted levels of attrition. We planned to

For continuous data, we used the mean difference if outcomes

We assessed statistical heterogeneity in each meta-analysis using

Measures of treatment effect

Assessment of reporting biases

excluded from the analyses in order to assess whether this made

Five studies were included in the review making the comparison

Different materials or techniques, or both, for closure of the

One study was identified that compared continuous suture closure

Single versus double layer closure of the uterine incision

Twenty-six studies were excluded from the review, with 14

Risk of bias in included studies

Incomplete outcome data

Other potential sources of bias

Methods of performing the uterine incision (including

Automatic stapler versus conventional uterine incision

Two trials (Villeneuve 1990; Von Rechenberg 1990) compared

Blunt versus sharp extension of the uterine incision

Direction of blunt extension of the uterine incision:

A single trial compared transverse with cephalad-caudad blunt

Single versus double layer closure of the uterine

Suturing materials and techniques for uterine closure