• A Dhanya Mackeen, Vincenzo Berghella, and Mie-Louise Larsen.
• Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas JeffersonUniversity, Philadelphia, Pennsylvania, USA.
• Cochrane Db Syst Rev. 2012 Nov 14; 11 (11): CD003577CD003577.

BackgroundCaesarean section is a common operation with no agreed upon standard regarding certain operative techniques or materials to use. With regard to skin closure, the skin incision can be re-approximated by a subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women.ObjectivesTo compare the effects of skin closure techniques and materials on maternal and operative outcomes after caesarean section.Search MethodsWe searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012).Selection CriteriaAll randomized trials comparing different skin closure materials in caesareans were selected. Two review authors independently abstracted the data.Data Collection And AnalysisWe identified 19 trials and included 11, but only eight trials contributed data. Three trials were not randomized controlled trials; two were ongoing; one study was terminated and the results were not available for review; one is awaiting classification; and one did not compare skin closure materials, but rather suture to suture and drain placement.Main ResultsThe two methods of skin closure for caesarean that have been most often compared are non-absorbable staples and absorbable subcutaneous sutures. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with similar incidences of wound infection. Other important secondary outcomes, such as wound complications, were also similar between the groups in women with Pfannenstiel incisions. However, it is important to note, that for both of these outcomes (wound infection and wound complication), staples may have a differential effect depending on the type of skin incision, i.e., Pfannenstiel or vertical. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with an increased risk of skin separation, and therefore, reclosure. However, skin separation was variably defined across trials, and most staples were removed before four days postpartum.Authors' ConclusionsThere is currently no conclusive evidence about how the skin should be closed after caesarean section. Staples are associated with similar outcomes in terms of wound infection, pain and cosmesis compared with sutures, and these two are the most commonly studied methods for skin closure after caesarean section. If staples are removed on day three, there is an increased incidence of skin separation and the need for reclosure compared with absorbable sutures.

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