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

<b>Background:</b> 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 intra- and postoperative maternal and neonatal outcomes in EPCD compared with transperitoneal CD (TPCD). <b>Methods:</b> 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). <b>Results:</b> 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. Five-minute Apgar scores were comparable between the two techniques (<i>p</i> = 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; <i>p</i> = 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, <i>p</i> = 0.017). Postoperative pain at 24 h was lower after EPCD (<i>p</i> < 0.001), and time to first gas passage was shorter (7.4 ± 2.7 h vs. 14.7 ± 2.7 h, <i>p</i> < 0.001) compared with TPCD. Other perioperative outcomes were comparable. <b>Conclusions:</b> The safety of EPCD for the neonate requires further investigation. Maternal postoperative pain and time to gas passage were favorable in EPCD.