Which Transverse Incisions Are Best for Cesarean Deliveries?


One incision is associated with better outcomes and potential cost savings.

In cesarean sections, the Joel-Cohen incision, compared with other incision types, seems to be associated with better outcomes, according to an intervention review conducted by the Cochrane Pregnancy and Childbirth Group.1
The most common surgery performed in women worldwide is the cesarean section. However, the operative techniques for this surgery, including the incision type, are varied. To better understand the risks and benefits of certain abdominal incisions, researchers extracted data from 4 studies involving a total of 666 women who underwent a cesarean section. The intent of all included studies was to perform cesarean sections using different abdominal incisions.
The specific incisions evaluated in this review are the Joel-Cohen incision, the Pfannenstiel incision, and the Maylard incision, all of which are transverse abdominal incisions. The Joel-Cohen incision, which includes blunt separation of tissue long natural planes, is a linear incision placed several centimeters above the Pfannenstiel incision, which is a curvilinear incision generally concealed in the regrowth of pubic hair when correctly placed just above the pubic symphysis.2 The Maylard incision-a muscle-cutting incision-is a variant of the Pfannenstiel incision; among their differences is in how the anterior rectus sheath and the rectus muscles are approached.2
In the 2 studies (411 women) that compared the Joel-Cohen incision with the Pfannenstiel incision, the Joel-Cohen incision was associated with a 65% reduction in postoperative febrile morbidity. In one of the studies, the Joel-Cohen incision also was associated with reduced postoperative analgesic requirements, reduced operating time, reduced delivery time, reduced total dose of analgesia in the first 24 hours, reduced estimated blood loss, reduced postoperative hospital stay for the mother, and increased time to the first dose of analgesia.
The other 2 included studies compared muscle-cutting incisions with the Pfannenstiel incision, but only 1 of these studies, which compared the Maylard incision with the Pfannenstiel incision and included 97 women, contributed data to the analysis. The review authors found no differences between incision types in febrile morbidity, need for blood transfusion, wound infection, and postoperative muscle strength during the hospital stay or at a 3-month follow-up examination.
A limitation of this review is that none of the included studies provided incision-specific data on severe or long-term morbidity and mortality. Overall, however, the available data show that the Joel-Cohen incision has advantages over the Pfannenstiel incision for the mother that could encompass potential cost savings for the health care system.

Pertinent Points:
- For cesarean sections, the Joel-Cohen incision was associated with better outcomes than the Pfannenstiel incision, including fewer postsurgical fevers, less postoperative pain, less blood loss, shorter duration of surgery, and shorter hospital stay.
- Information about incision type and associated severe or long-term morbidity and mortality are lacking.


1. Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database Syst Rev. 2013;5:CD004453. DOI: 10.1002/14651858.CD004453.pub3.
2. Lanneau GS, Muffley P, Magann EF. Chapter 74: Surgical techniques. In: Sciarra JJ, Steege JS, Summitt RL Jr, et al. Gynecology and Obstetrics. Vol 1-6. 2004 ed. Available at: http://www.glowm.com/resources/glowm/cd/pages/v2/v2c074.html. Accessed June 14, 2013.

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