What is the preferred incision type for a cesarean section (C-section)?

Preferred Incision Type for Cesarean Section

The transverse uterine incision is the preferred incision type for cesarean section due to lower rates of uterine rupture in subsequent pregnancies, reduced surgical blood loss, and better overall maternal outcomes compared to vertical incisions. 1, 2

Types of Cesarean Incisions

Transverse Incisions

• The low transverse uterine incision (Pfannenstiel) is the standard approach for most cesarean deliveries, made approximately 2-3 cm above the pubic symphysis 2
• Blunt expansion of the transverse uterine hysterotomy is recommended to reduce surgical blood loss 1
• Cephalad-caudad expansion technique is preferred over transversal expansion, as it is associated with fewer unintended extensions and less blood loss 3
• The transverse incision has a lower incidence of incisional hernia, reduced negative impact on pulmonary function, lower rates of wound dehiscence, and decreased postoperative pain compared to midline approaches 2

Vertical Incisions (Classical)

• Vertical hysterotomy (classical cesarean section) should be reserved for specific situations where access to the lower uterine segment is difficult 4
• Indications for vertical incision include:
  • Preterm labor with undeveloped lower uterine segment
  • Dense adhesions preventing access to the lower segment
  • Placenta previa/accreta 4
• The most serious risk of vertical incision is uterine rupture in subsequent pregnancies, making trial of labor contraindicated after classical cesarean section 4

Evidence Supporting Transverse Incisions

• The perinatal mortality rate associated with low transverse incision is significantly lower than with low vertical incision (41 versus 92 deaths per 1000 births) 5
• Transverse incisions generally have better outcomes than vertical incisions regarding wound complications and postoperative pain 2
• Closure of the hysterotomy in 2 layers is associated with a lower rate of uterine rupture and niche formation 1

Special Considerations

Placenta Covering Anterior Wall

• In cases of placenta covering the entire anterior uterine wall, alternative approaches may be considered:
  • Transverse fundal incision method 6
  • Rotation of the uterus to access the posterior wall for a lower transverse incision 7
• These specialized techniques should be reserved for cases where standard anterior wall incision poses significant risks 6, 7

Surgical Technique Recommendations

• The peritoneum does not need to be closed as closure is not associated with improved outcomes and increases operative times 1
• In women with ≥2 cm of subcutaneous tissue, reapproximation of that tissue layer should be performed to reduce wound complications 1
• The skin should be closed with subcuticular suture in most cases to reduce wound separation 1

Infection Prevention

• Intravenous antibiotics should be administered routinely within 60 minutes before the cesarean delivery skin incision 8
• Chlorhexidine-alcohol is preferred to aqueous povidone-iodine solution for abdominal skin cleansing 8
• Vaginal preparation with povidone-iodine solution should be considered for reducing post-cesarean infections 8

Anesthesia and Perioperative Care

• Regional anesthesia is the preferred method for cesarean delivery as part of an enhanced recovery protocol 1
• Appropriate patient monitoring with forced air warming, intravenous fluid warming, and increased operating room temperature is recommended to prevent hypothermia 1
• Perioperative and intraoperative euvolemia are important factors for improved maternal and neonatal outcomes 1

The evidence strongly supports the use of transverse uterine incisions for cesarean delivery in most clinical scenarios, with vertical incisions reserved only for specific situations where the lower uterine segment cannot be safely accessed.