Techniques for caesarean section

Caesarean sections are performed as both elective and urgent procedures and the rates are rising. The major complications are intraoperative damage to organs, anaesthetic complications, bleeding, infection and thromboembolism. The techniques used vary considerably. Available evidence from randomised controlled trials suggests that the Joel-Cohen based techniques (Joel-Cohen, Misgav-Ladach) have short-term advantages over Pfannenstiel (11 trials) and traditional lower midline (two trials) methods. Blood loss, operating time, time from skin incision to birth of the baby, use of pain killers, time to oral intake and bowel function or mobilisation and fever are all reduced.

Use of Joel-Cohen based methods could result in improved short-term outcomes and savings for health systems but robust data on long-term outcomes (pain, fertility, morbidly adherent placenta and rupture of the uterus) after the different techniques (including two suture layers compared with single-layer uterine closure) are needed.

Authors' conclusions: 

'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

[Note: The 19 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

Read the full abstract...

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique.


To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers. We updated this search on 15 February 2012 and added the results to the awaiting classification section.

Selection criteria: 

Randomised controlled trials of intention to perform caesarean section using different techniques.

Data collection and analysis: 

Two review authors independently assessed studies and extracted data.

Main results: 

'Joel-Cohen based' compared with Pfannenstiel CS was 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);
shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes);
postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours);
less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81);
shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours);
fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); 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).
Serious complications and blood transfusions were too few for analysis.