Evidence-based medical procedures to optimise caesarean outcomes: an overview of systematic reviews.

Background: The use of caesarean sections (CS) is increasing to unprecedented levels worldwide. As with any surgery, it has risks, and understanding the evidence base for interventions involved in a CS is essential to optimise outcomes and inform recommendations. We conducted an overview of systematic reviews (SRs) of randomised controlled trials (RCTs) to summarise the evidence on medical procedures used in CS.

Methods: Searches were conducted in Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACSs and CINAHL without date or language restrictions from database inception to January 31, 2024, with an updated search performed on January 24, 2025. We included SRs of RCTs that examined the effectiveness and safety of medical procedures used in CS. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306).

Findings: We identified 29 SRs (15 Cochrane and 14 non-Cochrane) published between 2002 and 2024 involving 408 unique RCTs including over 116,000 participants. Most reviews included trials from low- and middle-income countries (n = 21, 72.4%), combined both elective and emergency CS (n = 19, 65.5%), and were of high quality (n = 18, 62%), while 24.3% (n = 7) were of low and 13.7% (n = 4) were of critically low quality. The SRs presented 512 procedure-outcome comparisons (271 procedure versus procedure, 241 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 350 comparisons (68.4%), clear evidence of benefit for 97 (18.9%), possible benefit for 48 (9.3%), clear or possible no difference of effect for 9 (1.8%), clear evidence of harm for 4 (0.8%) and possible harm for 4 (0.8%). We found no SRs for 13 pre-specified procedures. Indwelling bladder catheter and its immediate removal, vaginal preparation with antiseptic solution, antibiotic prophylaxis, early oral intake, and abdominal binders are associated with benefits for some outcomes. There are no SRs on post-CS wound care, stitch removal, or time to resume sexual or physical activity, among others.

Interpretation: There are numerous gaps in the available evidence on medical procedures used in CS that require additional research. There is an urgent need for international recommendations to guide healthcare providers and policymakers in ensuring safer, evidence-based, care for women undergoing CS.

Funding: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).