目的:确定降低剖宫产产妇发病率的方法。
方法:按照GRADE®方法评估文献的证据质量,并以PICO格式(患者,干预,比较,结果)和结果先验定义,并根据其重要性进行分类。在PubMed上进行了广泛的书目搜索,Cochrane和EMBASE数据库。评估了证据的质量(高,中度,低,非常低)和(i)强或(ii)弱建议或(iii)没有提出建议。与外部审稿人(Delphi调查)在两轮中对建议进行了审查,以选择共识建议。
结果:在27个问题中,工作组和外部审查人员就26项达成协议。文献的证据水平不足以就15个问题提出建议。建议预防体温过低,以增加产妇的满意度和舒适度(弱推荐),并减少新生儿体温过低(强推荐)。文献证据的质量不允许推荐使用皮肤消毒剂,也不允许术前阴道消毒的相关性,也不允许选择使用或不使用留置膀胱导管(如果排尿发生在剖宫产前1小时)。应考虑使用Misgav-Ladach技术或其类似物,而不是Pfannenstiel技术,以降低产妇发病率(弱推荐)在子宫切口之前不应常规进行膀胱皮瓣(弱推荐),但是,应考虑采用钝器(弱推荐)和头尾扩大子宫切口(弱推荐)以降低产妇发病率。建议预防抗生素以降低母体感染发病率(强烈推荐),而不推荐其类型或给药时机(切口前或脐带夹闭后)。脐带夹闭后卡贝缩宫素的给药不会显着降低>1000ml的失血发生率,贫血,或输血与催产素相比。因此,不建议在剖宫产中使用卡贝缩宫素而不是催产素。建议不要进行系统的人工去除胎盘(弱推荐)。在局部区域麻醉下计划剖宫产的妇女应在脐带夹闭后使用止吐药,以减少术中和术后恶心和呕吐(强烈推荐),而不推荐使用一种或两种止吐药。文献的证据水平不足以提供有关单层或双层子宫切口闭合的任何建议。或者子宫外化术。不应考虑关闭腹膜(内脏或顶叶)(弱推荐)。文献证据的质量不足以提供系统性皮下闭合的建议,包括肥胖或超重患者,或在肥胖或超重患者中使用表皮下缝合。由于在外部审查回合中没有达成共识,因此与通过钉书钉闭合皮肤相比,不建议使用表皮下缝合线。
结论:在剖宫产的情况下,预防体温过低,在脐带夹闭后给予止吐和抗生素预防是唯一强有力的建议.Misgav-Ladach技术,进行子宫切口的方式(没有系统的膀胱皮瓣,钝的头尾延伸),不进行常规人工切除胎盘或关闭腹膜是弱建议,可能会降低产妇发病率.
To identify procedures to reduce maternal morbidity during cesarean.
The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.
Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.
In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.