RAMB Julho/Agosto 2015

esarean

request

ssoc

ras

2015; 61(4):296-307

297

quest OR patient preference OR demand OR medical in-

dication OR medical indications).

Cochrane

Strategy:

cesarean section AND request.

Studies retrieved (4/15/2014) (Table 1)

TABLE 1

Number of studies retrieved with the search

strategies used for each scientific database.

Database

Number of studies

Primary

PubMed-Medline

1,482

Cochrane

Inclusion criteria for studies retrieved

Selection of studies, assessment of titles and abstracts ob-

tained from the search strategy in the consulted databases

was conducted by two researchers with skills in the prepa-

ration of systematic reviews, both independent and blind-

ed, strictly observing the inclusion and exclusion criteria

previously established. All potentially relevant studies were

identified. Whenever the title and the summary were not

enlightening, researchers sought the full article.

Study design

Narrative reviews, case reports, case series and studies pre-

senting preliminary results were excluded from the as-

sessment. Systematic reviews and meta-analyzes were used

with the basic purpose of recovering references that per-

haps had been lost at first, from the initial search strate-

gy. Only comparative nonrandomized studies (strength

of evidence 2B and 2C) were included.

P.I.C.O. components

•

Patient: nulliparous or multiparous patients under-

going cesarean section on maternal request or with-

out medical indication, at term, pre- or intra-labor,

and women undergoing planned vaginal delivery at

term.

•

Intervention: cesarean section on maternal request

or cesarean delivery without medical indication.

•

Comparison: patients undergoing planned vaginal

delivery.

•

Outcome: the outcomes were divided into maternal

outcomes, newborn outcomes and emergency cesare-

an. Maternal outcomes include: maternal death, bleed-

ing complications, infectious complications, wound

complications, complications in breastfeeding. Bleed-

ing complications were defined in the study as bleed-

ing ≥ 1,000mL, need for blood transfusion after deliv-

ery, need for curettage due to placental persistence,

anemia, prolonged vaginal bleeding and hysterectomy

caused by bleeding. Maternal infectious complications

are defined as urinary tract infections, endometritis

and sepsis. Wound complications were classified as

wound infection, dehiscence or pain. Complications

in breastfeeding are defined as mixed feeding or feed-

ing with formula only. Newborn outcomes include:

Apgar score lower or equal to 7, asphyxia, respiratory

complications, infection, and need for admission to

neonatal ICU. Asphyxia was defined as pH of venous

blood or blood cord lower than 7.0. Respiratory com-

plications were defined according to studies of respi-

ratory distress syndrome of the newborn, use of CPAP,

need for ventilation, and dyspnea or tachypnea.

Language

The authors included studies available in Portuguese,

English, French or Spanish.

According to publication

Only studies with full text available were considered for

critical assessment.

Studies selected in the first assessment

Using the search strategy described, 1,482 studies were

retrieved. Out of these, which were reviewed based on ti-

tle, only 295 articles included the subject cesarean deliv-

ery on maternal request or C-section without medical in-

dication, and thus 1,187 studies were excluded. Of the

295 studies, only 73 were selected for full text review, be-

ing considered for final evaluation 9 comparative stud-

ies (observational cohorts) that met the criteria for inclu-

sion and exclusion (Flowchart 1).

Evidence selected in critical evaluation and exhibition of results

The studies considered for full text reading were critical-

ly assessed according to inclusion and exclusion criteria,

study design, P.I.C.O., language and availability of the

full text.

Results of the clinical situations are displayed in Ta-

bles 4, 5 and 6.

References related to the studies included are shown in

Table 3, and are also presented in the section References.

After applying the inclusion and exclusion criteria,

the evidence selected in the search and defined as ran-

domized controlled trials (RCT) were subjected to an ap-

propriate checklist for critical assessment (Table 2). Crit-