Review of Unsafe Changes in the Practice of Cesarean Section with Analysis of Flaws in the Interpretation of Statistics and the Evidence

Author Info

Shashikant L SHOLAPURKAR

Corresponding Author

Shashikant L SHOLAPURKAR
Department of Obstetrics & Gynaecology, Royal United Hospital NHS Trust, Bath, UK

A B S T R A C T

Cesarean section is the commonest major operation. Unfortunately, many recent practice-changes have been rushed based on flawed interpretation limited data that are debated in this review. The discussion includes non-closure of the peritoneum, the 39-week rule for elective cesarean, incorrect implementation of four-category urgency classification, and abdominal entry with excessive blunt force. It took NASA two fatal space-shuttle disasters over 18 years to change its culture of dismissing reasoning and observations in addition to numerical data. Reasoning becomes even more important when there is emerging data, especially in soft sciences like medicine. This review discusses flawed science behind the change to “non-closure of peritoneum” in details (and other changes briefly). This practice change was based on narrow mistaken considerations and solely on statistical significance, studying irrelevant short-term outcomes like increased requirement of analgesia. Several statistical mistakes in interpreting this evidence with wider applications are discussed. This weak/flawed evidence has been subsequently disproven by large randomized controlled trials. Small reduction in operating time should never have been a consideration. The merit of hypothesis favoring peritoneal closure to prevent adhesions is very strong to begin with. More importantly, the meta-analysis of available studies shows that closing peritoneum significantly reduces the formation of adhesions, particularly the severe ones. Extensive adhesion of uterus to the abdominal wall is relatively rare to reach statistical significance in small studies but is clinically highly significant due to operative complications. The rushed mistaken recommendation of non-closure of peritoneum should not have been made. However, reversing these changes is perceived as admitting errors, and there is simply no interest in doing so with detriment of the patients. Guidelines should now change their advice on many important aspects of cesarean, as discussed in this review.

Article Info

Article Type

Clinical Review

Publication history

Received: Mon 08, Feb 2021
Accepted: Fri 19, Mar 2021
Published: Tue 13, Apr 2021

Copyright

© 2023 Shashikant L SHOLAPURKAR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.SCR.2021.03.18