RAMB Maio/Junho 2015

irth

route

case

cesarean

section

pregnancy

ssoc

ras

2015; 61(3):196-202

197

sections OR section, repeat cesarean OR sections, repeat

cesarean) AND (trial of labor OR vaginal birth after ce-

sarean OR vaginal birth after cesareans OR vaginal births

after cesarean).

Cochrane

Strategy:

repeat cesarean section.

Studies retrieved (5/1/2014) (Table 1)

TABLE 1

Number of studies retrieved according to the

search strategies used for each scientific database.

Database

Number of studies

Primary

PubMed-Medline

584

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 (see item 2). All potentially relevant

studies were identified. Whenever the title and the summa-

ry were not enlightening, researchers sought the full article.

1. 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 missed in the initial search strategy. Stud-

ies designed as cohort or controlled clinical trials (ran-

domized or not) were included.

Cohort study was defined as those with follow-up of pa-

tients, equal history, and analysis of prognostic outcomes.

Controlled clinical trials were evaluated according to

the Jadad score.

2. P.I.C.O. components

•

Patient: women in labor of a term singleton fetus in

cephalic presentation, who had babies delivered by

cesarean section in previous births (cesarean delivery

performed by means of transverse uterine section).

•

Intervention:

elective cesarean section.

•

Comparison:

vaginal delivery.

•

Outcomes related to maternal morbidity and mor-

tality: maternal death, uterine rupture, hysterectomy

scar dehiscence (total or partial), hemorrhagic com-

plications (bleeding in the intra- and post-partum

period requiring blood transfusion), retention of pla-

cental remains, hysterectomy related to any birth

complications, vulvar or perineal hematoma (requir-

ing surgery), thromboembolic events, surgical wound

complications (wound infection, dehiscence or pain),

puerperal infection, bowel, bladder or ureter injury

requiring surgical treatment, occurrence of fistula in-

volving the urinary, genital or gastrointestinal tracts,

pulmonary edema, postpartum depression. Late ma-

ternal outcomes include complications in breastfeed-

ing, perineal pain, abdominal pain, dyspareunia, uri-

nary incontinence, fecal incontinence, genital

dystopia, occurrence of low insertion of placenta or

placenta accreta/percreta in future pregnancies.

3. Language

We included studies available in Portuguese, English,

French or Spanish.

4. According to publication

Only studies with full text available were considered for

critical assessment.

Studies selected in the first assessment

After entering the search strategy in the primary databas-

es (PubMed-Medline and Cochrane), the assessment of

titles and abstracts led to the selection of nine studies.

Evidence selected after 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 (items 1, 2, 3 and 4).

Results pertaining clinical status will be displayed in-

dividually showing the following items: clinical question,

number of studies selected (according to inclusion crite-

ria), description of the studies (Table 2), results and sum-

mary of the available evidence.

References related to the studies included are shown in

Table 4.

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 3). Crit-

ical assessment of RCTs allows to classify them according

to the Jadad score, so that trials with Jadad <3 are consid-

ered inconsistent (

), and those with scores ≥3, consis-