As with most surgical procedures, there is no standard technique for cesarean delivery. The following discussion will review each step in the procedure and provide evidence-based recommendations for surgical technique, when these data are available.
OPENING THE ABDOMEN
The advantages and disadvantages of various incisions and the procedure for opening the abdomen from skin to peritoneum are generally the same as for gynecologic procedures. (See "Incisions for open abdominal surgery".)
Transverse or vertical? — For most patients, we prefer a transverse incision since it is associated with less postoperative pain, greater wound strength, and better cosmetic appearance than the vertical midline incision. We rarely perform a vertical incision. We use a vertical incision when we believe it will be faster and the incision-to-delivery time is critical, as well as when we believe a transverse incision may not provide adequate exposure or may be too prone to hematoma formation. Vertical incisions generally allow faster abdominal entry , cause less bleeding and nerve injury, and can be easily extended cephalad if more space is required for access. (See "Incisions for open abdominal surgery".)
Two common transverse incisions for cesarean delivery are the Pfannenstiel type and the Joel-Cohen type incisions. The Pfannenstiel skin incision is slightly curved, 2 to 3 cm above the symphysis pubis, with the midportion of the incision within the shaved area of the pubic hair. The Joel-Cohen incision is straight, 3 cm below the line that joins the anterior superior iliac spines, and slightly more cephalad than Pfannenstiel .
In meta-analyses of randomized trials of surgical incisions for cesarean delivery, the Joel-Cohen type incision had significant short-term advantages compared with the Pfannenstiel incision, including lower rates of fever, pain, and use of analgesia; less blood loss; and shorter operating time (overall and incision-to-delivery) and hospital stay [3,4]. In two trials (411 women) that compared the Joel-Cohen incision with the Pfannenstiel incision, the Joel-Cohen incision resulted in a 65 percent reduction in reported postoperative febrile morbidity (RR 0.35, 95% CI 0.14-0.87); one trial reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40-0.76), operating time (mean difference [MD] -11.40, 95% CI -16.55 to -6.25 minutes), delivery time (MD -1.90, 95% CI -2.53 to -1.27 minutes), total dose of analgesia in the first 24 hours (MD -0.89, 95% CI -1.19 to -0.59), estimated blood loss (MD -58.00, 95% CI -108.51 to -7.49 mL), postoperative hospital stay for the mother (MD -1.50, 95% CI -2.16 to -0.84 days), and increased time to the first dose of analgesia (MD 0.80, 95% CI 0.12 to 1.48 hours) . No other significant differences were found in either trial.