What is the best cesarean section technique to minimize morbidity and mortality?

Best Cesarean Section Technique

The Joel-Cohen (modified Misgav-Ladach) incision is the superior technique for cesarean section, demonstrating significant reductions in operative time, postoperative pain, blood loss, and hospital stay compared to the traditional Pfannenstiel incision. 1, 2, 3

Surgical Technique: Skin and Fascial Incision

Use the Joel-Cohen incision for abdominal entry (Grade A recommendation). This technique involves:

• A straight transverse skin incision 3 cm below the line joining the anterior superior iliac spines 2, 3
• The incision is positioned higher than the traditional Pfannenstiel incision 3, 4
• Blunt fascial opening rather than sharp dissection, which further reduces postoperative pain 1, 2

The evidence is compelling: the Joel-Cohen technique reduces total operative time by approximately 11 minutes (mean difference -11.40 minutes, 95% CI -16.55 to -6.25), reduces baby extraction time by nearly 2 minutes, and decreases estimated blood loss by 58 mL compared to Pfannenstiel 3. Multiple randomized trials confirm these findings, with one study showing operative times of 29.81 minutes versus 32.67 minutes for Pfannenstiel 4, and another demonstrating extraction times of 90 seconds versus 208 seconds 5.

Uterine Incision and Delivery

• Perform a transverse lower uterine segment incision as the standard approach 2, 6
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 2
• Avoid creating a bladder flap when opening the uterus, as this results in clinically-relevant improvements in postoperative pain 1
• Perform in situ closure of the uterus rather than exteriorization, which causes more postoperative pain 1

Critical exception: In cases of morbidly adherent placenta, perform the uterine incision 2-3 cm above the placental border using the transverse-transverse technique (Pfannenstiel skin with upper transverse LUS incision), which results in significantly less blood loss and shorter operative time compared to vertical-vertical incisions 7. The transverse-transverse approach in these high-risk cases reduces intraoperative blood loss, blood product consumption (erythrocyte suspension, FFP, cryoprecipitate, and thrombocyte suspension all significantly lower, p<0.01), and has better cosmetic outcomes 7.

Uterine and Abdominal Closure

Close the uterine hysterotomy in 2 layers, as this is associated with lower rates of uterine rupture in subsequent pregnancies 2

Do not close the peritoneum (Grade A recommendation). This outdated practice:

• Increases operative time without any benefit 1, 2
• Shows no improvement in outcomes according to Cochrane review 1
• Has minimal evidence for reduced pain when left open 1

For subcutaneous tissue: Reapproximate the layer only if ≥2 cm thick 2

For skin closure: Use subcuticular sutures rather than staples, as this reduces wound separation when staples would be removed at 4 days 2

Pre-operative Analgesia Protocol

Administer the following before skin incision:

• Intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) - Grade A recommendation 1, 2
• Oral paracetamol - Grade A recommendation 1, 2

This combination provides superior postoperative analgesia. If epidural is used (such as in combined spinal-epidural), epidural morphine 2-3 mg or diamorphine up to 2-3 mg may substitute 1.

Intra-operative Interventions (After Delivery)

Administer immediately after cord clamping:

• Intravenous paracetamol if not given pre-operatively - Grade A 1, 2
• Intravenous NSAIDs - Grade A 1, 2
• Intravenous dexamethasone for pain control and anti-emetic prophylaxis - Grade A 1, 2

If intrathecal morphine was NOT used, add local anesthetic wound infiltration (single-shot or continuous infusion) and/or fascial plane blocks such as transversus abdominis plane (TAP) blocks or quadratus lumborum blocks - Grade A 1, 2. However, these regional techniques provide minimal additional benefit when combined with intrathecal morphine 2.

Postoperative Pain Management

• Oral or intravenous paracetamol - Grade A 1, 2
• Oral or intravenous NSAIDs - Grade A 1, 2
• Opioids for rescue only when other strategies fail or are contraindicated 1, 2
• Elastic abdominal binders - Grade A recommendation, showing clinically-relevant reductions in pain scores and rescue analgesia 1, 2
• Transcutaneous electrical nerve stimulation (TENS) as adjunct therapy 1, 2

Infection Prevention

• Administer intravenous antibiotics within 60 minutes before skin incision (not after cord clamping) 2
• Use first-generation cephalosporin as standard 2
• Add azithromycin for women in labor or with ruptured membranes for additional infection reduction 2
• Chlorhexidine-alcohol for abdominal skin cleansing 2
• Vaginal preparation with povidone-iodine solution to reduce postcesarean infections 2

Anesthesia

Regional anesthesia (spinal or epidural) is strongly preferred over general anesthesia as part of enhanced recovery protocols 1, 2. Regional techniques:

• Avoid risks of general anesthesia 1
• Significantly obtund the stress response including hyperglycemic response 1
• Allow immediate maternal-infant bonding 1

Critical Pitfalls to Avoid

Never delay antibiotic administration until after cord clamping - this outdated practice significantly increases maternal infection risk 2

Avoid closing the peritoneum - this increases operative time by several minutes without any demonstrated benefit and contradicts current evidence 1, 2

Do not use staples for skin closure if removing at 4 days - subcuticular sutures demonstrate reduced wound complications 2

Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine/dexmedetomidine - these have limited evidence and concerning side effects in the obstetric population 2

Do not omit basic analgesics (paracetamol and NSAIDs) when using intrathecal morphine - they work synergistically and the multimodal approach is superior to opioids alone 1, 2

Never use the Pfannenstiel incision when Joel-Cohen is available - the evidence overwhelmingly favors Joel-Cohen for reduced pain (65% reduction in febrile morbidity, RR 0.35,95% CI 0.14-0.87), reduced analgesic requirements (RR 0.55,95% CI 0.40-0.76), and shorter hospital stay (mean difference -1.50 days, 95% CI -2.16 to -0.84) 3

Avoid exteriorizing the uterus for closure - in situ closure results in less postoperative pain, though one meta-analysis showed no difference 1