WITHDRAWN: Absorbable staples for uterine incision at caesarean section.

BACKGROUND: Staples can be placed during the making of an incision, with the aim of decreasing blood loss from the cut edges. OBJECTIVES: The objective of this review was to assess the effects of using a stapler with absorbable staples to extend the uterine incision at lower segment caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised and quasi-randomised trials of extending the uterine incision using a stapler compared with extending the incision digitally or with scissors in women having a lower segment transverse incision caesarean section. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed. MAIN RESULTS: Four trials involving 526 women were included. There was no difference in total operating time between the stapling technique and other techniques to extend the incision (weighted mean difference -1.17 minutes, 95% confidence interval -3.57 to 1.22). However stapling devices increased the time needed to deliver the baby (weighted mean difference 0.85 minutes, 95% confidence interval 0.48 to 1.23). Blood loss was lower with the use of staples (weighted mean difference -41.22 millilitres, 95% confidence interval -50.63 to -31.8). No significant differences between stapling and other techniques were detected for other perinatal morbidity outcomes. AUTHORS' CONCLUSIONS: There is not enough evidence to justify the routine use of stapling devices to extend the uterine incision at lower segment caesarean section. There is a possibility that stapling could cause harm, by prolonging the time to deliver the baby.

WITHDRAWN: Lateral tilt for caesarean section.

BACKGROUND: When pregnant women near term lie in the supine position the uterus can compress the inferior vena cava, interfering with venous return to the heart. This can result in hypotension, reduced placental perfusion and decreased fetal oxygenation. OBJECTIVES: The objective of this review was to assess the effects on the fetus or newborn of lateral tilt at caesarean section compared to the operation carried out with the mother in the supine position. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised or quasi-randomised trials of lateral tilt (10 to 15 degrees) compared to supine position during caesarean section in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were done by one reviewer. MAIN RESULTS: Three trials involving 293 women were included. The trials were all methodologically poor. There were fewer low Apgar scores when lateral tilt was used, and pH measurements and oxygen saturation appeared to be better when tilt was used. AUTHORS' CONCLUSIONS: There is not enough evidence from these trials to evaluate use of lateral tilt during caesarean section.

WITHDRAWN: Manual removal of placenta at caesarean section.

BACKGROUND: Although manual removal of the placenta is commonly carried out, opinions differ about the best technique for delivery of the placenta at caesarean section. OBJECTIVES: The objective of this review was to assess the effects of manual removal of the placenta at caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing manual removal of placenta to spontaneous separation and controlled cord traction for delivery in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were done by one reviewer. MAIN RESULTS: Three trials involving 224 women were included. The trials were of reasonable quality. Manual removal of the placenta was associated with a clinically important and statistically significant increase in maternal blood loss (weighted mean difference 436.35, 95% confidence interval 347.82 to 524.90). Manual removal was also associated with increased post-partum endometritis (odds ratio 5.44, 95% confidence interval 1.25 to 23.75) and a statistically non-significant trend towards an increase in feto maternal haemorrhage (odds ratio 2.19, 95% confidence interval 0.69 to 6.93). AUTHORS' CONCLUSIONS: The evidence suggests that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection.

WITHDRAWN: Single versus two layer suturing for closing the uterine incision at Caesarean section.

BACKGROUND: A single layer closure might save operating time, disrupt less tissue, introduce less foreign material into the wound, and thus result in less post operative morbidity. OBJECTIVES: The objective of this review was to assess the effects of a single layer closure of the uterine incision at caesarean section, in contrast to conventional two layer closure. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials of single layer closure, either interrupted or continuous, compared to two layer closure with continuous sutures in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality and extracted data. MAIN RESULTS: Two trials involving 1006 women were included. Based on one trial, single layer closure was associated with reduced operating time (5.6 minutes). Based on one trial, radiographic scar appearance showed fewer scar defects at three months with the single closure group. There were no statistically significant differences in the use of extra haemostatic sutures, incidence of endometritis, decrease in post operative haematocrit or use of blood transfusion. AUTHORS' CONCLUSIONS: There appear to be no advantages or disadvantages for routine use of single layer closure compared to two layer closure, except perhaps a shorter operation time.

The path towards eHealth: obstacles along the way.

OBJECTIVES: The two authors of this article share both a strong interest in, and deep concerns about, the use of eHealth (electronic information and communication technologies for improving or maintaining health). In this article, we identify some unanticipated obstacles to effective use of eHealth. METHODS: We reflected upon the potential of information and communication technologies to transform the health system and its failure to achieve that potential. RESULTS: We chose seven obstacles: the insufficient emphasis on health in eHealth, the lack of time for reflection, the development of a fortress mentality, poor evaluation of efforts, lack of involvement of youth, inequity, and a parochial attitude that precludes economies of scale. Whenever possible, we provided examples of innovative initiatives that illustrate potential ways to meet our current challenges. CONCLUSION: We believe that the obstacles we describe in this article can be overcome. The impediments are not only technological, but also cognitive, financial and political. To succeed will require a major shift from our ethic of competition to one of generosity, commitment, and collaboration; enlightened, as opposed to narrow, self-interest.

Absorbable staples for uterine incision at caesarean section.

BACKGROUND: Staples can be placed during the making of an incision, with the aim of decreasing blood loss from the cut edges. OBJECTIVES: The objective of this review was to assess the effects of using a stapler with absorbable staples to extend the uterine incision at lower segment caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised and quasi-randomised trials of extending the uterine incision using a stapler compared with extending the incision digitally or with scissors in women having a lower segment transverse incision caesarean section. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed. MAIN RESULTS: Four trials involving 526 women were included. There was no difference in total operating time between the stapling technique and other techniques to extend the incision (weighted mean difference -1.17 minutes, 95% confidence interval -3.57 to 1.22). However stapling devices increased the time needed to deliver the baby (weighted mean difference 0.85 minutes, 95% confidence interval 0.48 to 1.23). Blood loss was lower with the use of staples (weighted mean difference -41.22 millilitres, 95% confidence interval -50.63 to -31.8). No significant differences between stapling and other techniques were detected for other perinatal morbidity outcomes. REVIEWER'S CONCLUSIONS: There is not enough evidence to justify the routine use of stapling devices to extend the uterine incision at lower segment caesarean section. There is a possibility that stapling could cause harm, by prolonging the time to deliver the baby.

Uterine exteriorization versus intraperitoneal repair at caesarean section.

BACKGROUND: After caesarean delivery of the fetus and placenta, the uterus may be placed outside the mother to facilitate repair of the uterine incision. OBJECTIVES: The objective of this review was to assess the effects of exteriorisation of the uterus, compared to the effects of uterine closure within the abdominal cavity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised and quasi-randomised trials of uterine exteriorisation for repair compared to intra-abdominal repair for pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted the data. MAIN RESULTS: Two trials involving 486 women were included. Neither trial was methodologically strong. Exteriorisation made no significant difference to blood loss. Exteriorisation was associated with fewer post-operative febrile days (fever more than three days, odds ratio 0.40, 95% confidence interval 0.17 to 0.94) and a non-significant trend towards fewer infections. There was also a non-significant trend towards more nausea and vomiting when exteriorisation was done under regional analgesia. REVIEWER'S CONCLUSIONS: There is not enough information to evaluate the routine use of exteriorisation of the uterus for repair of the uterine incision.

Lateral tilt for caesarean section.

BACKGROUND: When pregnant women near term lie in the supine position the uterus can compress the inferior vena cava, interfering with venous return to the heart. This can result in hypotension, reduced placental perfusion and decreased fetal oxygenation. OBJECTIVES: The objective of this review was to assess the effects on the fetus or newborn of lateral tilt at caesarean section compared to the operation carried out with the mother in the supine position. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised or quasi-randomised trials of lateral tilt (10 to 15 degrees) compared to supine position during caesarean section in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were done by one reviewer. MAIN RESULTS: Three trials involving 293 women were included. The trials were all methodologically poor. There were fewer low Apgar scores when lateral tilt was used, and pH measurements and oxygen saturation appeared to be better when tilt was used. REVIEWER'S CONCLUSIONS: There is not enough evidence from these trials to evaluate use of lateral tilt during caesarean section.

Manual removal of placenta at caesarean section.

BACKGROUND: Although manual removal of the placenta is commonly carried out, opinions differ about the best technique for delivery of the placenta at caesarean section. OBJECTIVES: The objective of this review was to assess the effects of manual removal of the placenta at caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing manual removal of placenta to spontaneous separation and controlled cord traction for delivery in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were done by one reviewer. MAIN RESULTS: Three trials involving 224 women were included. The trials were of reasonable quality. Manual removal of the placenta was associated with a clinically important and statistically significant increase in maternal blood loss (weighted mean difference 436.35, 95% confidence interval 347.82 to 524.90). Manual removal was also associated with increased post-partum endometritis (odds ratio 5.44, 95% confidence interval 1.25 to 23.75) and a statistically non-significant trend towards an increase in feto maternal haemorrhage (odds ratio 2.19, 95% confidence interval 0.69 to 6.93). REVIEWER'S CONCLUSIONS: The evidence suggests that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection.

Peritoneal non-closure at caesarean section.

BACKGROUND: It has been suggested that the peritoneal suture might be omitted during caesarean section without adverse effects. OBJECTIVES: The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intra-operative and immediate postoperative outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Controlled trials comparing leaving the visceral and/or parietal peritoneum unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted by two reviewers. MAIN RESULTS: Four trials involving 1194 women were included. Non-closure of the peritoneum saved operating time (weighted mean difference of -6.12 minutes, 95% confidence interval -8.00 to -4.27) with no significant differences in postoperative morbidity, analgesic requirements and length of hospital stay. There was a consistent, although nonsignificant, trend for improved immediate postoperative outcome if the peritoneum was not closed. REVIEWER'S CONCLUSIONS: There seems to be no significant difference in short term morbidity from non-closure of the peritoneum at caesarean section.

Single versus two layer suturing for closing the uterine incision at caesarean section.

BACKGROUND: A single layer closure might save operating time, disrupt less tissue, introduce less foreign material into the wound, and thus result in less post operative morbidity. OBJECTIVES: The objective of this review was to assess the effects of a single layer closure of the uterine incision at caesarean section, in contrast to conventional two layer closure. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials of single layer closure, either interrupted or continuous, compared to two layer closure with continuous sutures in pregnant women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality and extracted data. MAIN RESULTS: Two trials involving 1006 women were included. Based on one trial, single layer closure was associated with reduced operating time (5.6 minutes). Based on one trial, radiographic scar appearance showed fewer scar defects at three months with the single closure group. There were no statistically significant differences in the use of extra haemostatic sutures, incidence of endometritis, decrease in post operative haematocrit or use of blood transfusion. REVIEWER'S CONCLUSIONS: There appear to be no advantages or disadvantages for routine use of single layer closure compared to two layer closure, except perhaps a shorter operation time.

Using anecdotal information in evidence-based health care: heresy or necessity?

Anecdotes are powerful tools that humans use to make decisions. Despite their power and influence, they are sometimes misused, and sometimes undervalued. Ignoring or under-estimating the role of anecdotal information in health care decisions is likely to hinder communication among decision makers, and to retard their uptake of research evidence. Anecdotal information should not be considered as a replacement for, but as a complement to formal research evidence. If evidence-based health care is to meet its potential, the important role of anecdotes must be acknowledged, studied and utilized.

The effects of whirlpools baths in labor: a randomized, controlled trial.

BACKGROUND: Showers and tubs in labor were not generally used in our center. When three whirlpool baths (Jacuzzis) were ordered as part of our renovations, a randomized, controlled trial was initiated to explore their effects on narcotic and epidural requirements. METHODS: This study employed an intent-to-treat design, and the sample size was estimated to account for the fact that some women would be unable to use the tub. The experimental group of 393 women was offered the tub during labor and the control group of 392 women received conventional care. RESULTS: No births occurred in the tub. The tub group required fewer pharmacologic agents than controls (66% vs 59%, p = 0.06), experienced fewer deliveries by forceps and vacuum (p = 0.019), and were more likely to have an intact perineum than the standard-care group (p = 0.019). Labor was longer for the tub group (p = 0.003), who coincidentally were more primiparous and in earlier labor on admission. No differences were noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes. A subset of mothers expressed satisfaction with the tub experience and labor support. The cesarean rate among both groups was lower (8.9%) than our overall rate (16.6%) during the study period. CONCLUSIONS: Whirlpool baths in labor have positive effects on analgesia requirements, instrumentation rates, condition of the perineum, and personal satisfaction. Further study is being planned.

Collecting the evidence systematically. Ensuring that it is complete and up-to-date.

A complete and comprehensive search of the relevant evidence is an essential step in the preparation of a scientific systematic review. The Cochrane Pregnancy and Childbirth Database consists of some 600 systematic reviews, based on almost 6,000 randomized or quasi-randomized trials of care during pregnancy and childbirth. As ascertainment from electronic search of the National Library of Medicine MEDLINE database was not complete, the mainstay of our search strategy was a systematic hand search of some 60 journals, beginning with volumes published in 1950. Additional references were obtained from the list of references in primary research reports and conference reports. A major effort was made to identify unpublished trials and to obtain unpublished data from published trials.

Effective care in pregnancy and childbirth: a synopsis.

Evidence about the effects of care practices is not a sufficient guide to the most appropriate care. Those who provide care, who receive care, who advocate care, or who pay for care must choose on the basis of many factors: personal experience, personal preference, personal values, availability of resources and facilities, and a myriad of other considerations, among which knowledge of the effects of care is certainly important. This knowledge is essential for choices to be properly informed. The most reliable evidence about the effects of care is provided by randomized controlled trials. Unfortunately, this evidence is not readily accessible. It is scattered through a large number of journals throughout the world, and is hidden among a mass of weak, inadequate, and sometimes frankly misleading studies. Those who wish to use all the valid evidence must rely on properly prepared, up-to-date, systematic reviews. The Cochrane Collaboration has taken on the task of preparing, maintaining, and disseminating reviews of randomized trials of health care, published electronically as the Cochrane Database of Systematic Reviews. The reviews are provided by a number of Collaborative Review Groups, and the Cochrane Pregnancy and Childbirth Database is the first specialty database to appear. It is regularly updated to incorporate data that have become available since the previous issue.