Surgical techniques for caesarean section

The Joel-Cohen-based techniques for caesarean section, which include blunt separation of tissues along natural tissue planes with a minimum of sharp dissection and non-closure of both layers of the peritoneum, have advantages over Pfannenstiel and traditional (lower midline) caesarean section techniques in terms of short-term outcomes such as operation time, fever and estimated blood loss.

RHL Commentary by Abalos E


Caesarean section rates have been rising worldwide over the past decades in both developed and developing countries (1, 2, 3). In the WHO Global Survey on Maternal and Perinatal Health, which was conducted between 2004 and 2005 in 24 regions of eight countries in Latin America and which obtained data for all women admitted for delivery in 120 randomly selected institutions, the median rate of caesarean delivery was 33%; rates of up to 51% were noted in private hospitals (4). Results from the WHO Global Survey show that increased caesarean section rates are associated with a higher risk of postpartum antibiotic treatment and severe maternal morbidity and mortality as well as an increase in fetal mortality rates, with a higher number of babies admitted to intensive care units for 7 days compared with babies born through vaginal deliveries (4).

Given that the operation is conducted so frequently, any attempt to reduce risks associated with it (even with relatively modest alterations in the surgical procedure for a particular outcome) is likely to yield significant benefits in terms of costs and better health outcomes for women. This commentary covers two Cochrane reviews: (i) Techniques for caesarean section (5), which sought to compare outcomes of various methods of caesarean section (Joel-Cohen, Misgav-Ladach, modified Misgav-Ladach, Pfannenstiel, the traditional lower midline abdominal incision, and extraperitoneal/intraperitoneal caesarean section techniques) and to summarize the findings of reviews of individual aspects of caesarean section techniques; and (ii) Abdominal surgical incisions for caesarean section (6), which sought to "determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section". For a better understanding of the differences between types of incision and closure of tissue layers in different surgical technique see Table 1 (under "Related documents" in the inset box).


Overall, the two reviews are comprehensive. They include all adequately controlled trials that could be identified. The respective authors of the two reviews contacted the authors of published abstracts and researchers associated with unpublished data or ongoing studies for details on methodology and/or results, evaluated the included trials for methodological quality and appropriateness for inclusion, and followed generally sound methods in the conduct of the reviews.


3.1. Techniques for caesarean section

This review includes 14 trials involving 2950 women who had undergone an elective or an emergency caesarean section. The primary outcome measures were serious intraoperative and postoperative complications, including organ damage, significant sepsis, thromboembolism, organ failure, high-care unit admission or death; blood loss and blood transfusion. Secondary outcomes included short-term outcomes for the woman (such as operating time, maternal death, admission to intensive care unit, anaemia, wound infection, endometritis, time to mobilization, time to oral intake of food and drink, time to breastfeeding initiation, repeat operative procedures on the wound, pain, or satisfaction with care), short-term outcome measures for the infant (such as time from skin incision to delivery, birth trauma, cord blood pH, Apgar score, neonatal intensive care admission, encephalopathy, and neonatal or perinatal death). Longer-term outcomes for the mother (such as long-term wound complications, pain, fertility problems, or complications in future pregnancies or surgeries) were also collected, as well as outcomes related to health service use (length of postoperative hospital stay for mother or baby, readmission of mother or baby to hospital, or of both, and related costs).

For the purposes of this review authors classified the "Joel-Cohen", "Misgav-Ladach" and "modified Misgav-Ladach" methods as subgroups of the "Joel-Cohen-based" techniques. Compared with Pfannenstiel caesarean section, the Joel-Cohen-based methods were associated with less blood loss, [five trials, 481 women; weighted mean difference (WMD) −64.45 ml; 95% confidence interval (CI) −91.34 to −37.56 ml]. Serious complications and blood transfusions were too few for a meaningful analysis. The Joel-Cohen-based methods were also associated with: shorter operating time (five trials, 581 women; WMD −18.65; 95% CI −24.84 to −12.45 minutes); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28–0.81); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD −3.84 minutes; 95% CI −5.41 to −2.27 minutes).

Only two trials compared Misgav-Ladach versus traditional (lower midline abdominal) incision. The Misgav-Ladach method was associated with: reduced blood loss (WMD −93.00; 95% CI −132.72 to −53.28 ml); less operating time (WMD −7.30; 95% CI −8.32 to −6.28 minutes); less time to mobilization (WMD −16.06; 95% CI −18.22 to −13.90 hours); and reduces duration of postoperative stay in hospital for the mother (WMD −0.82; 95% CI −1.08 to −0.56 days). All these results come from one trial that involved 339 women. No significant differences were found between Misgav-Ladach versus traditional incision in terms of postoperative anaemia, wound infection, wound breakdown, endometritis, or fever.

One 1974 study, which was not sound methodologically, compared extraperitoneal and intraperitoneal caesarean section techniques. No reliable conclusions could be drawn from that trial. The review authors also reviewed all pre-, intra-, and post-operative procedures related to caesarean sections.

3.2. Abdominal surgical incisions for casearean section

This review includes four trials involving 576 women. Two studies compared the Joel-Cohen incision with Pfannenstiel incision for laparotomic access, and the other two compared transverse muscle-cutting incisions (Mouchel and Maylard) with the Pfannenstiel incision. The main outcome measures were postoperative febrile morbidity, need for analgesia, blood loss and blood transfusion. Secondary outcomes included duration of surgery, operative or postoperative complications, anaemia, pyrexia, infection, wound complications, time to mobilization, time to oral intake of food and drink, time to breastfeeding initiation, length of hospital stay, satisfaction with the operation, and appearance of the scar. Secondary outcomes for the baby included time from anaesthesia to delivery, Apgar score, cord blood pH, birth trauma, admission to special care baby unit and encephalopathy. Other outcomes included caregiver’s satisfaction and costs.

The Joel-Cohen incision showed less postoperative febrile morbidity than the Pfannenstiel incision (two trials, 411 women; RR 0.35; 95% CI 0.14–0.87). Postoperative analgesic requirements were also less in the Joel-Cohen group (one trial, 101 women; RR 0.55; 95% CI 0.40–0.76), as well as the estimated blood loss (WMD −58.00; 95% CI −108.51 to −7.49 ml). Other secondary outcomes such as operating time, delivery time, the total dose of analgesia, and postoperative hospital stay for the mother also favored the Joel-Cohen group.

No studies directly compared the Joel-Cohen incision versus vertical incision. Only one of the two studies comparing muscle cutting incisions with Pfannenstiel incision reported outcomes of interest for this review. This study included 97 women and compared the Maylard incision with the Pfannenstiel incision. No differences in febrile morbidity, blood transfusion, postoperative hospital stay or wound infection were reported between the two groups. No economic analyses were conducted in the studies included in the review.

4. Discussion

4.1. Applicability of the results

Trials included in the review Techniques for caesarean section (5) were conducted in China, Germany, India, Italy, Portugal, Senegal, South Africa, and Sweden; one of the trials had been conducted in 1974 and the rest between 1998 and 2002. There was some variation in the details of the techniques defined by the authors as "Joel-Cohen", "Misgav-Ladach", and "modified Misgav-Ladach" techniques, and not all trials reported years of qualification of staff performing the procedures. Data about mother satisfaction, health service use and long-term outcomes such as subsequent fertility, morbidly adherent placenta, and uterine rupture were not provided by the trial authors.

Trials in the second review (6) were conducted in India, France and Switzerland – one in 1989, and the other three in 2002. Again, experience of the surgeon, as well as other procedures during the operation, such as the antibiotic prophylaxis, were not described.

Based on the results of the reviews, it seems that blunt separation of tissues along natural tissue planes, using a minimum of sharp dissection, that is, the Joel-Cohen based techniques, have advantages compared with the Pfannenstiel and traditional (lower midline) caesarean section techniques. However, febrile morbidity, postoperative infection rates, antibiotic use, wound complications, haemorrhage, pain, need for analgesia and length of stay in hospital reflect short-term outcomes. The long-term morbidity outcomes are difficult to evaluate within the context of randomized controlled trials. Adhesions may be asymptomatic in most cases and to show a difference among the symptoms (pain, dyspareunia) or other morbidity (such as secondary infertility) a large number of women would need to be evaluated. Direct and indirect costs to both the health system and users were not evaluated in these trials.

4.2. Implementation of the intervention

Techniques for caesarean section. The evidence from this review suggests a beneficial effect of the Joel-Cohen-based techniques. In health-care facilities considering a change in practice, some education and training of health-care staff would be necessary to ensure that the health-care workers have the skills to identify intra-operative complications. If a change in policy is planned, adequate record-keeping and follow-up of women for detection of clinically relevant complications in both the short and long term will be desirable.

Abdominal surgical incisions for caesarean section. The Joel-Cohen incision appears to have advantages compared with the Pfannenstiel incision. The above-mentioned concerns about settings considering change in practice also apply here.

4.3. Implications for research

Future research should be aimed at evaluating costs of the operation and women's views on postoperative discomfort associated with particular surgical techniques. Clinically relevant short as well as long-term benefits or complications of the above-mentioned procedures need to be evaluated in large randomized controlled trials. Closure versus non-closure of the peritoneum was one of the interventions evaluated in 3031 women recruited to the CAESAR Study  a multicentre factorial randomized controlled trial conducted in 47 hospitals throughout the United Kingdom and Italy (7). Results are expected to be published in 2009. Another international, fractional factorial randomized controlled trial and is being conducted in 20 hospitals in Argentina, Chile, Ghana, India, Kenya, Pakistan and Sudan (8). Blunt versus sharp incision, and closure versus non-closure of the peritoneum (pelvic and parietal) are two of the five pairs of interventions being compared. The trial aims to recruit 15 000 women worldwide and is expected to finish recruitment by the end of 2010.

Sources of support: Centro Rosarino de Estudios Perinatales. Rosario. Argentina.

Acknowledgements: none.


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This document should be cited as: Abalos E. Surgical techniques for caesarean section: RHL commentary (last revised: 1 May 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.