Perinatal Outcomes in Extra vs. Transperitoneal Cesarean Delivery - A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Q: What was the purpose of this systematic review and meta-analysis?

To compare intra- and postoperative maternal and neonatal outcomes between extraperitoneal cesarean delivery (EPCD) and transperitoneal cesarean delivery (TPCD) using randomized controlled trials.

Q: Which databases and study type were included?

Six databases were searched for English-language studies up to August 2025, including only peer-reviewed randomized controlled trials directly comparing EPCD and TPCD.

Q: What maternal and neonatal outcomes showed differences between EPCD and TPCD?

Five-minute Apgar scores were comparable, umbilical artery pH <7.2 was higher with EPCD, incision-to-delivery time was longer with EPCD, and 24-hour postoperative pain and time to first gas passage were more favorable with EPCD.

Sep 30, 2026

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Background: Despite observational indications that extraperitoneal cesarean delivery (EPCD) may offer advantages, evidence remains limited and prior studies often enrolled small samples. This systematic review evaluates intra- and postoperative maternal and neonatal outcomes comparing EPCD with transperitoneal cesarean delivery (TPCD). Methods: Six databases were searched for English-language studies from inception to August 2025, including only peer-reviewed RCTs directly comparing EPCD and TPCD; bias was assessed with the Cochrane tool. Outcomes focused on Apgar score and postoperative pain. Results: Seven RCTs with 758 women were eligible; five-minute Apgar was similar, while umbilical artery pH <7.2 favored TPCD. EPCD showed longer incision-to-delivery time but lower 24-hour postoperative pain and faster first gas passage. Conclusions: Neonatal safety needs further study, while maternal postoperative pain and time to gas passage favored EPCD.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages11

Reading Time28 min

AccessFree to download

Abstract

Background

Methods

Results

Conclusions

1. Introduction

Systematic Review Perinatal Outcomes in Extra vs. Transperitoneal Cesarean Delivery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Manal Massalha 1,2, Kamel Mattar 3, Rula Iskander 1, Mais Abu Nofal 3, Ido Izhaki 4 and Raed Salim 3,5, * Academic Editor: Everett F. Magann Received: 29 November 2025 Revised: 23 December 2025 Accepted: 23 December 2025 Published: 26 December 2025 Copyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. 1 Department of Obstetrics and Gynecology, Emek Medical Center, Afula 1834111, Israel; [manal.massalha@clalit.org.il](manal.massalha@clalit.org.il) (M.M.); [rola_is@clalit.org.il](rola_is@clalit.org.il) (R.I.) 2 The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel 3 Department of Obstetrics and Gynecology, Holy Family Hospital, Nazareth 1641105, Israel; [kamel.mattar@mail.huji.ac.il](kamel.mattar@mail.huji.ac.il) (K.M.); [maisabunofal@gmail.com](maisabunofal@gmail.com) (M.A.N.) 4 Department of Evolutionary and Environmental Biology, University of Haifa, Haifa 3103301, Israel; [izhakido@gmail.com](izhakido@gmail.com) 5 Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel * Correspondence: [r.salim@hfhosp.org](r.salim@hfhosp.org); Tel.: +972-54-498-6960 Abstract Background: Despite the advantages of extraperitoneal cesarean delivery (EPCD) indicated by observational studies, there is little accurate evidence supporting this technique, and the studies performed have included small numbers of participants. We aimed to examine intraand postoperative maternal and neonatal outcomesinEPCD compared with transperitoneal CD (TPCD) . Methods: Six databases restricted to English-language studies were searched from inception to August 2025 . Only peer-reviewed randomized controlled trials (RCTs) directly comparing EPCD and TPCD were included. Study quality was evaluated using the Cochrane Risk of Bias tool. Primary neonatal and primary maternal outcomes were the Apgar score and postoperative pain, respectively. The protocol was prospectively registered in PROSPERO (\#CRD42023420365) . Results: Of the 69 reports identified, seven RCTs comprising 758 women (379 per group) were eligible. Data for 1 min Apgar scores were insufficient for analysis because standard deviations were missing for most studies. Fiveminute Apgar scores were comparable between the two techniques (p = 0.91) . Incidence of umbilical artery pH < 7.2 was higher in the EPCD group than in the TPCD group (7.9% vs. 2.3%, respectively; p = 0.047). Mean incision-to-delivery time was longer in the EPCD group (7.5 ± 5.0 min) compared with the TPCD group (6.2 ± 3.7 min, p = 0.017) . Postoperative pain at 24 h was lower after EPCD (p < 0.001), and time to first gas passage was shorter (7.4 ± 2.7 h vs. 14.7 ± 2.7 h, p < 0.001) compared with TPCD. Other perioperative outcomes were comparable. Conclusions: The safety of EPCD for the neonate requires further investigation. Maternal postoperative pain and time to gas passage were favorable in EPCD. Keywords: extraperitoneal cesarean delivery; maternal outcome; meta-analysis; neonatal outcome; randomized controlled trials 1. Introduction Cesarean delivery (CD) is the most frequent surgical operation performed worldwide [1] . Though the rates of maternal morbidity and mortality related to the procedure are relatively low, it is vital that surgeons consistently use evidence-based techniques that have been shown to reduce surgical complications. Several aspects of the surgery are supported by evidence with a high level of certainty. Nevertheless, there is little available evidence regarding several other aspects, and their practice is largely based on the surgeon’s preference [1] . The standard technique for CD in most medical

FAQs

What was the purpose of this systematic review and meta-analysis?

To compare intra- and postoperative maternal and neonatal outcomes between extraperitoneal cesarean delivery (EPCD) and transperitoneal cesarean delivery (TPCD) using randomized controlled trials.

Which databases and study type were included?

Six databases were searched for English-language studies up to August 2025, including only peer-reviewed randomized controlled trials directly comparing EPCD and TPCD.

What maternal and neonatal outcomes showed differences between EPCD and TPCD?

Five-minute Apgar scores were comparable, umbilical artery pH <7.2 was higher with EPCD, incision-to-delivery time was longer with EPCD, and 24-hour postoperative pain and time to first gas passage were more favorable with EPCD.

Sep 30, 2026

Upload by Indoniesian Boy