The Effect of Non-pharmacological Interventions on Blood Loss During and
After Caesarean Section: a Systematic Review and Network Meta-analysis
Abstract
Background & Objective Blood loss during and after caesarean
section is a key determinant of maternal mortality, especially in low-
and middle-income countries. This systematic review aimed to identify
effective non-pharmacological interventions for reducing blood loss
during and after caesarean section. Search Strategy Multiple
databases were searched from inception to December 2023.
Selection Criteria Prospective studies of women undergoing
caesarean section assessing non-pharmacological interventions reporting
estimated blood loss and/or post-partum haemorrhage were included.
Retrospective studies and study populations not representative of the
general caesarean section cohort were excluded. A difference in blood
loss of >250ml or a relative risk reduction in post-partum
haemorrhage of >25% was considered clinically important.
Data Collection and Analysis Data was double extracted. Network
meta-analyses and conventional pairwise meta-analyses were performed
where appropriate. Risk of bias was assessed using Cochrane RoB 2 or
ROBINS-I tools. Main Results 97 studies were eligible for
inclusion. 40 were synthesised in five distinct network meta-analyses
(caesarean section surgical technique, placenta removal technique,
timing of umbilical cord clamping, peritoneum closure and patient
warming) and 36 in six pairwise meta-analyses (staple uterine incision,
sharp versus blunt expansion of uterine incision, cervical dilatation,
extra versus intra-abdominal uterine repair, suture material, and one
versus two-layer uterine closure). None of the intervention groups were
associated with a clinically important effect. Conclusions The
published trials of non-pharmacological interventions on blood loss
associated with caesarean section are inconclusive. There is a need for
collaborative trials to identify effective and generalisable
interventions. A key focus should be interventions that may be impactful
in low resource settings where blood loss is the dominant determinant of
maternal mortality related to caesarean section.