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Clinical Guideline
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CAESAREAN SECTION
SETTING Maternity Services, St Michael’s Hospital

FOR STAFF Medical, nursing and midwifery staff

PATIENTS Patients undergoing caesarean section procedure

_____________________________________________________________________________

GUIDANCE
This is a practical guide to elective and emergency Caesarean section (CS). Antenatal
provision of information and Vaginal Birth after Caesarean is not covered in this guideline.

Women requesting CS without obstetric indication

For pathway see appendix 1

Consent for CS

Written consent should be obtained even in emergencies. Risks of caesarean section

should be explained as per the RCOG Consent Advice No 7; discussion should include
risks to the mother and the fetus, as well as implications for future pregnancies and birth
after CS. Fetal risks include cuts to the skin (approximately 2 in 100 cases) and respiratory
morbidity (particularly for Elective CS).
For Elective CS use the UHBristol Caesarean Specific Consent form –v2 (Appendix 2).
However, it is recognized that in severe emergencies (Category 1 CS only) verbal consent
is appropriate. The decision and the reasons for verbal consent must be documented.
A competent pregnant woman is entitled to refuse the offer of treatment such as CS, even
when the treatment would clearly benefit her or her baby’s health. Such a refusal and the
relevant risks associated with it must be clearly documented in the notes.
A consultant obstetrician or ST6/7 should be involved in the decision for CS unless doing
so would be life threatening to the mother of fetus.
The person making the decision for CS must clearly document the indications
 In the maternal hand held record
 On the operation note (Medway delivery record)

Urgency Categorisation

The urgency of CS should be documented using the following scheme in order to aid
clear communication between healthcare professionals about the urgency.

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Category 1: Immediate threat to the life of the woman or fetus
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 Includes CS for acute severe bradycardia, cord prolapse, uterine rupture, fetal
blood sampling pH less than 7.2.
 Deliver as quickly as possible taking into account rapid delivery may be
harmful incertain circumstances.
 Decision to delivery audit standard = within 30 minutes
Category 2: Maternal or fetal compromise which is not immediately life-
threatening
 There is ‘urgency’ to deliver the baby in order to prevent further deterioration
of either the mother or baby’s condition.
 Deliver as quickly as possible, in most situations within 75 minutes, taking into
account rapid delivery may be harmful in certain circumstances.
 Decision to delivery audit standard = within 30 and 75 minutes
Category 3: No maternal or fetal compromise but needs early delivery
 Includes CS carried out where there is no maternal or fetal compromise but
early delivery is necessary e.g. breech with ruptured membranes
 Includes LSCS at < 37 weeks gestation for maternal or fetal reasons
 Decision to delivery standard = within 24 hours
Category 4: Elective CS
 Includes all CS carried out at a planned time to suit the mother and
maternity team

Emergency Caesarean (Category 1, 2 & 3)

Emergency CS for maternal or fetal compromise should be undertaken within the time
frames relevant to the category of urgency. However, it must be taken into account that
emergency situations have the potential to cause psychological trauma to the mother.

Fetal distress:
Start Intra-Uterine Resuscitation
 Stop syntocinon
 Turn mother to left lateral
 Administer terbutaline 250 mcg SC
 Start / Increase IV fluids
 Administer facial 02

The time of decision (surgeon decides and woman consents in writing) and reasons for
any delay in undertaking category 1 or 2 CS must be documented in both
 the partogram
 the operative note (Medway delivery record)

Pre-operative requirements
 Inform coordinating midwife who will liaise with the Anaesthetist and Theatre
coordinator (use 2222 call for category 1 CS)
 Ensure woman is wearing an appropriate identification bracelet and check
with the woman that the details on it are correct
 Obtain informed consent
 Site cannula if IV access not already established

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 Send bloods for FBC and G&S if not already done
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 Administer Ranitidine 150 mg orally or 50mg IV (prescription required)

 Put on anti-embolic stockings
 Mother to remove jewellery and underwear
 Put theatre gown on mother if time
 Transfer to theatre as quickly as possible
 Maintain left lateral position until anaesthesia is initiated (cat 1 and 2 only)
 Continue Fetal Monitoring until surgeon ready to commence (cat 1 and 2
only)
 Insert indwelling urinary catheter once anaesthesia effective
 Shave pubic area if time
 Call neonatologist
The surgeon should assist in the transfer to theatre unless there is an urgent need
for them elsewhere.
 On arrival into theatre there must be clear communication of the patient’s
name, reason for caesarean section and urgency category.
 The urgency category may change once the patient is in theatre i.e. following
recovery of a fetal bradycardia, and in this instance clear communication is
required within the team.
 The operating surgeon must be ready for knife-to-skin as soon as adequate
anaesthesia is achieved, particularly for category 1 CS.
 The surgeon should communicate with the neonatologist if there any
additional concerns i.e. possible fetal sepsis or hypovolaemia
 It is the responsibility of the attending neonatologist to determine whether
senior support is required.

Elective Caesarean (Category 4)

The risk of respiratory morbidity is increased in babies born by CS before labour, but this
risk decreases significantly after 39 weeks.

 Planned CS should not routinely be carried out before 39 weeks.

 The reason should be clearly documented if a planned CS is performed
before 39 weeks.
 If CS for Breech presentation with no other obstetric indication inform the
woman that a scan will be performed on the morning of admission and if no
longer breech a caesarean will not be required.

There is evidence that antenatal steroids can reduce the need for NICU admissions if an
elective CS has to be performed before 39 weeks. This should be discussed on an
individual patient basis.

Maternal Haemoglobin should be optimised antenatally to aim for a HB ≥110g/l at the time
of elective section, if Haemoglobin <110 g/l at 36 weeks consider need for intravenous iron.

Booking elective CS in clinic

1. Written consent should be obtained by the obstetrician booking the CS (use the
procedure specific consent form - appendix 2)
2. The CS date should be booked in the Caesarean Section diary by calling ANC on ext
25299/ 25297

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3. re Give the patient’s name, hospital number, EDD, gestation on the date of Caesarean (in
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weeks and days), indication and the named Consultant Obstetrician. Highlight any
potential intraoperative risks.
4. Ensure the woman’s correct telephone number is recorded in the diary
5. Give the woman the UHBristol Caesarean Section – Enhanced Recovery information
leaflet and explain that the woman will be contacted on the evening before the planned
CS to confirm the time of admission on the day of the procedure
6. Explain that occasionally the CS date may be changed if there is a need to re-prioritise
cases due to clinical workload or complex cases
7. Arrange pre-op clerking appointment within 7 days of the agreed CS date
8. Provide anti-embolic stockings with instructions
The following may be done at the time of booking the CS or at a pre-op clerking
appointment:
9. Arrange an anaesthetic review (bleep 2923)
10. A Group and Save (G&S) and a full blood count (FBC) should be taken within 7 days of
the agreed CS date.
11. Prescribe and supply antacid/ anti-emetic regimen (premeds) and pre-op drinks.
Women should be given instruction on the timing of their medications according to the
time of admission on the day of the CS.
Early admission
 Take ranitidine at 10 pm
 Come in at 8am
o No food from 2am
o Clear fluids until 6am
o Take medication/ pre-op drinks at 6am
Late admission
 Take ranitidine at 10 pm
 Come in at 10am
o No food from 5am
o Clear fluids until 9am
o Take medication/ pre-op drinks at 9am
12. Provide Chlorhexidine skin wash and advise the woman to shower using this on the
morning of the CS.

Elective CS in Women with Diabetes

 Delivery recommended by 38 weeks in women with Type 1 and Type 2
Diabetes
 Steroids should be considered if CS undertaken before 38 weeks with
Supplementary insulin cover to optimise maternal glycaemic control; see
guideline Supplementary IV Insulin Following Betamethasone
 Women with diabetes should not receive pre-op drinks
 When CS prioritised should be first on the operating list
 If requires insulin in pregnancy will need sliding scale insulin
perioperatively; see guideline Diabetes in pregnancy Intrapartum Care

Practicalities of the Elective CS List

Elective CS lists are held daily on normal working days.
During the CDS handover the obstetrician responsible for running the CS list will be
identified; this may be the Consultant, ST 6-7 or ST3-5 dependent on the complexity of the
cases and the workload on CDS.
An extra obstetric SHO is allocated to help run this list, and is identified on the SHO rota.
If there is no dedicated ‘Section SHO’ then the SHO or consultant for CDS will assist.

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Theatre briefs take place at 8.30 (Mon-Thurs) and 9.00 am (Fri) to allow for patient review
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and pre-op checks between 8.00am to 8.30am.
The CS list will start promptly after the theatre brief.
The SHO should remain in theatre after the brief to complete the sign-in for the first patient.

The theatre brief should:

 Include the theatre practitioner, anaesthetic assistant, operating surgeon,
anaesthetist and midwife/ nurse caring for the women
 Determine list order
 Share information about potential anaesthetic or surgical problems

Emergency obstetric cases take priority over elective CS cases.

The reasons for any significant delay in elective CS must be recorded on a clinical incident
form and Medway.

Preoperative Checks

 Ensure woman is wearing an appropriate identification bracelet and check

with the woman that the details on it are correct
 Check FBC results and that the G&S is in date
 Check e-match status. In high-risk women (placenta praevia, coagulation
disorders etc.) liaise with the consultant obstetrician and anaesthetist to
decide whether to cross-match blood/ use intra-operative cell salvage
 Confirm the gestational age according to the dating scan
 Check presentation by ultrasound before CS for Breech presentation
 Note position of placenta on past ultrasound reports
 Verify consent on admission to CDS
 Sign the admission VTE risk assessment on the drug chart
 Once the patient is in theatre the surgeon undertaking the procedure verifies:
 the identity of the patient
 the procedure to be carried out
 consent
 The patient’s name and the procedure to be undertaken is written on the
board in theatre

All CS
Women’s preferences for the birth, such as lowering the screen to see baby born, choice
of music should be accommodated where possible. Only one partner/relative/friend is
allowed in theatre for CS under regional anaesthesia unless exceptional circumstances in
which case gain prior agreement with senior surgeon, anaesthetist, and CDS co-ordinator.
If under General Anaesthetic birth supporters are not allowed.
WHO Surgical Checklist will be undertaken at every CS, however in the event of a
category 1 CS the full check may be delayed until the situation allows a time out.
Neonatology attendance is required for all CS except elective (category 4) operations
unless there is evidence of fetal abnormality or fetal problems are anticipated.
Antibiotic Prophylaxis will be administered at all CS. Antibiotics will be administered
before knife to skin. Antibiotics effective against endometritis, urinary tract and wound
infections, which occur in about 8% of women who have had a CS, should be used (refer to
antibiotic policy).

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Delayed Cord Clamping consider delayed cord clamping for at least 1 minute unless
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immediate neonatal resuscitation is required or there is significant maternal blood loss.
Cord Gases Paired cord blood samples should be taken and analysed after all CS. Results
must be documented as per Monitoring the Fetus in Labour guideline.
Uterotonic agents
 Carbetocin 100 micrograms by slow intravenous injection should be given once
the baby is born to encourage contraction of the uterus and to decrease blood loss
 Syntocinon 5 – 10 units may be recommended for women with significant cardiac
disease (see Individualised maternal medicine care plans for recommended
management)
 If further uterotonics are required use oxytocin infusion, syntometrine (unless
contraindicated) and prostaglandins (misoprostol/ carboprost) as in guideline
Management of Obstetric Haemorrhage.
Thromboprophylaxis
 VTE Risk Assessment will be completed in line with the local guideline
Thromboprophylaxis During Pregnancy, Labour & Postnatal Period
 All women undergoing CS require anti-embolic stockings unless specifically
contraindicated
 Where appropriate prescribe Low Molecular Weight Heparin (Clexane)
Post CS information letter (appendix 3)
 Women delivering by their 1st or 2nd CS should have a ‘Post Caesarean
Information Letter’ completed by the surgeon when the operation notes are
written
 If the women is deemed not suitable for VBAC in a future pregnancy this letter
will not be completed and this will be indicated on the operation notes

Anaesthetic Care (see obstetric anaesthesia guideline)

The obstetrician informs the anaesthetist of the urgency category and indication
Women having a CS should be given information on different types of post-CS analgesia
so that analgesia best suited to their needs can be offered.
Women are encouraged to have CS under regional anaesthesia rather than GA because it
is safer and results in less maternal and neonatal morbidity. This includes women who
have a diagnosis of placenta praevia.
General anaesthesia for emergency CS should include preoxygenation, cricoid pressure
and rapid sequence induction to reduce the risk of aspiration.
The surgeon must be ready for immediate knife-to-skin.
The operating table for CS should have a lateral tilt of 15 degrees.

Surgical Technique
If problems are encountered timely senior support (ST6/7 or consultant) must be requested.
The surgeon should use the technique he/she is most familiar with and taking into account
the good practice points from the NICE guidance, these include:
 Follow infection control precautions. Wear double gloves for Serology positive
women.
 Use a Joel Cohen technique if possible (appendix 4)
 Blunt rather than sharp extension of the uterine incision results in less blood
loss and lower PPH incidence
 Repair the uterus in two layers
 Do not routinely exteriorize the uterus
 If possible use controlled cord traction and not manual removal of the

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placenta to reduce the risk of endometritis
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 Do not routinely close the visceral or the parietal peritoneum

 In the event that a midline abdominal wall incision is used, the abdominal wall
should be closed by a mass closure technique using slowly absorbable
sutures (PDS or equivalent)
 Routine closure of the fat layer does not reduce the incidence of wound
infection, however the fat layer should be closed where there is >2cm
subcutaneous fat

Post-Operative Care
Care will be administered as detailed in Recovery after Obstetric Operative
Intervention guideline
Early eating and drinking: Women who are recovering well after CS and who do not
have complications can eat and drink when they feel hungry or thirsty.
Urinary catheter removal: Removal of the urinary bladder catheter should be carried
out once a woman is mobile after a regional anaesthetic and not sooner than 12 hours
after the last epidural ‘top up’ dose or spinal.

Post CS discussion
The obstetrician undertaking the post-operative review on day 1 or 2 will:
 Ensure mother understands the indication for CS
 Discuss implications for future pregnancies before discharge
 Give the post CS information letter to the woman and discuss as appropriate
 Tick the box on the P/N review sticker to indicate that the letter has been
given and discussed

The process for continuous audit, multidisciplinary review of audit results and
subsequent monitoring of action plans.

Process Tool Responsibility Frequency Responsibility for: (plus timescales)

of: of review
Review of Development of Monitoring of Making
results action plan and action plan and improvement
recommendations implementation lessons to be
shared

Documentation Monthly at
of CDSWP
 Classification Multi- Presented
of Urgency professional Continuous quarterly to
Multi-professional Review and
of CS Continuous group Audit- Women’s See CDSWP
group undertakes monitoring
 Timing of all Clinical reporting to reviewed Services monitoring proforma
recommendations monthly at
grade 1 CS Audit CDS Working monthly at Clinical for dissemination of
and action planning CDSWP
 Reason for party CDSWP Audit learning
performing a (CDSWP) Meeting
grade 1 CS

The above table outlines the minimum requirements to be audited; additional audits will be
commissioned in response to deficiencies identified within the service through morbidity and
mortality reviews/benchmark data provided by CHKS or in response to national initiatives e.g. NICE,
RCOG guidelines, CNST standards
Version 5.2
Reviewed and Updated September 2015

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Authors
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Consultant Obstetrician
, Consultant Obstetrician
Specialist Registrar Obstetrics and Gynaecology
Patient Safety Midwife and Supervisor of Midwives
Practice Development Midwife & Supervisor of Midwives

Consultation
CDS Working Party, Antenatal Working party, Supervisors of Midwives

Ratified by
CDS Working Party October 2015

Date: Oct 15
Review Due: Oct 18

_____________________________________________________________________________

RELATED Thromboprophylaxis During Pregnancy, Labour & Postnatal Period

DOCUMENTS Recovery after Obstetric Operative Intervention
Monitoring the Fetus in Labour
Obstetric Anaesthesia guideline
Obs & Gynae Antibiotic Guideline
Anaemia Antenatal & Postnatal
Supplementary IV Insulin Following Betamethasone
Diabetes in pregnancy Intrapartum Care

REFERENCES  NICE guideline CG132 Caesarean Section November 2011

 NHS Litigation Authority – Clinical Negligence Scheme or Trusts (2001). Maternity –
Clinical Risk Management Standards
 RCOG Good Practice No 11. Classification of urgency of caesarean section – A
continuum of risk London 2010
 RCOG Consent advice No.7 Caesarean Section London October 2009
 Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M and Robinson PN
(2000).
Urgency of caesarean section-a new classification. Journal of the Royal Society of
Medicine, 93, 346-350
 RCOG - Clinical Effectiveness Support Unit (2001). The Use of Electronic Fetal
Monitoring: The use and interpretation of cardiotocography in intrapartum fetal
surveillance. Evidence-based Clinical Guideline Number 8. London: RCOG Press
 Thomas J, Paranjothy S. RCOG - Clinical Effectiveneness Support Unit (2001). The
national sentinel caesarean section audit report. London: RCOG Press
 Thomas J, Paranjothy S, James D (2004). National cross sectional survey to determine
whether the decision to delivery interval is critical in emergency caesarean section.
BMJ;328:665-7
 Tuffnell DJ Wilkinson K, Beresford N (2001). Interval between decision and delivery by
caesarean section – are current standards achievable? Observational case series.
BMJ;322:1330-3
 CEMACH – Why Mothers Die 2000-2002. RCOG press London.
 RCOG (2004). Obtaining Valid Consent. Clinical Governance Advice No. 6. London:
RCOG Press
 Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane
Database of Systematic Reviews 2007, Issue 1.

SAFETY There are no unusual or unexpected safety concerns to staff or patient.

QUERIES Contact Emma Treloar Bleep 2789 or the obstetric on call team on Central
Delivery Suite. Telephone 25213/4 for contact bleep numbers

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Appendix 1 Pathway for women requesting CS without obstetric indication
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Request for CS without obstetric indication made by the mother

Midwife or obstetrician identifying request must:

 Explore, discuss and record specific reasons for request
 Give and discuss caesarean section leaflet
Obvious mental
health disorder  Discuss and document overall risks and benefits of CS vs. vaginal birth
 Ensure ‘Help yourself to a normal birth’ patient information leaflet is
given and discussed
See Mental
Health in  Patients not already under Consultant Led care should be transferred to
Pregnancy consultant led care and referred to a Consultant Antenatal Clinic to
discuss their options further
Pathway (link)
 Include other members of the team if necessary to ensure she has
accurate information (e.g. consultant obstetrician, midwife, anaesthetist)

Previous birth Childbirth anxiety /

trauma identified tocophobia identified

Recommend: Recommend:
 Birth Trauma Association – website information;  IAPT (Improving Access to Psychological
some listeners available by phone and email; Therapies) – NHS provided
contact details for other mums in similar - Bristol – LIFT Psychology. Can self-refer on
situations (www.birthtraumaassociation.org.uk) 0117 982 3209
 Bluebell-07738 628 842 - Weston-super-Mare – Positive Steps. Can
 Womankind-0845 458 2914 self-refer on 0800 688 8010
 Mothers For Mothers-0117 9756006 - Gloucestershire – LIFT Psychology. Can
self-refer on 0117 378 4270

Consider referral to Psychological Health Services at Consider referral to Psychological Health Services at
St. Michael’s Hospital St. Michael’s Hospital

36/40 Consultant ANC

Offer and book elective caesarean section if vaginal birth

remains an unacceptable option or if an indication for caesarean
section develops during pregnancy e.g. breech presentation,
placenta praevia

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Consent Form 1 Hospital no: ______________________
Name of proposed procedure or course of treatment
Caesarean section NHS no: ______________________
An operation to deliver your baby/ babies through a cut in the Surname ______________________
tummy, this can be a planned procedure for example if the baby is
breech or you have had a previous caesarean section; or an Forename ______________________
emergency caesarean if there are complications of labour or
concerns about the wellbeing of you or your baby. Gender ______ D.o.B. ___ /___ /______

Statement of health professional (to be filled in by health

professional with appropriate knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits: Safe delivery of baby/babies in a situation where the risks of vaginal delivery are more
than those of a caesarean section operation

Serious or frequently occurring risks

Frequent risks:
 Common: persistent wound and abdominal discomfort, repeat caesarean section in subsequent
pregnancies, readmission to hospital, minor cuts to the baby’s skin
 Uncommon: haemorrhage (bleeding), infection, breathing difficulties in baby

Uncommon but Serious risks:

 Emergency hysterectomy (removal of the womb) , 7-8 women in every 1000 (uncommon)
 Need for further surgery at a later date, 5 women in every 1000 (uncommon)
 Admission to intensive care unit, 9 women in every 1000 (uncommon)
 Increased risk of a tear in the womb in future pregnancies, 2-7 women in every 1000 (uncommon)
 Developing a blood clot in the veins of the leg or lung, 4-16 women in every 10 000 (rare)
 Stillbirth in future pregnancies, 1-4 women in every 1000 (uncommon)
 In a future pregnancy, the placenta covers the entrance to the womb (placenta praevia), 4-8 women
in every 1000 (uncommon)
 Injury to the urinary system, 1 woman in every 1000 (rare)
 Injury to the bowel, 1 woman in every 1000 (rare)
 Death, approximately 1 woman in every 12 000 (very rare)

Any extra procedures which may become necessary during the procedure
 blood transfusion
 other procedures: hysterectomy(removal of the womb), repair to damaged organs

I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative
treatments (including no treatment) and any particular concerns of this patient.
 The following leaflet/tape has been provided: ____________________________________________
 This procedure will involve:  general and/or regional anaesthesia  local anaesthesia sedation
Doctor’s Signature ……………………………………………..….. Date ………………………………
Name (PRINT) ……………………………………………………… Job title …………………………..
Contact details (if patient wishes to discuss options later) ………………………….………………….

Top copy accepted by patient: yes/no (please ring)

Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way which I believe
he/she can understand.
Signature…………………………………………………………….. Date…………………………
Name (PRINT)………………………………………………..

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St Michaels’s Hospital
Southwell Street
Bristol
BS2 8EG
Tel: 0117 3425201
Name:
Address:
Hospital ID:
Dear
About your caesarean section
Congratulations on the birth of your baby on:
Your baby was born by caesarean section because:

After giving birth by caesarean most women are able to give birth vaginally in future
pregnancies. If you have another pregnancy you will be seen by an obstetrician as well as your
midwife and they will discuss your birth options with you. Most women (around 3 out of every 4)
who plan a VBAC (Vaginal Birth after Caesarean) go on to give birth to their next baby vaginally
and unless your obstetrician or midwife advises otherwise, we recommend that you plan for a
VBAC with any future baby.
If you would like to discuss anything arising from this letter or need any further information
clarified, please contact your community midwife in the first instance.
You can get further information from
 www.caesarean.org.uk
 www.Nct.org.uk or 0300 330 0700
 www.powertopush.ca
 National Institute of Clinical Excellence at
www.nice.org.uk/guidance?action=download&o=29336
 Association for Improvements in the Maternity Services: www.aims.org.uk or on
0300 365 0663. They also publish a booklet called ‘Birth after Caesarean’

Signed: Print Name:

Job Title: Date:

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Technique of Abdominal Incision for Caesarean Section

Pfannenstiel Incision
The traditional lower abdominal incision for caesarean delivery is the incision described in 1900
by Pfannenstiel. Classically, this incision is located two fingers-breadth above the pubic
symphysis. Here the skin may be entered via a low transverse incision that curves gently
upward, placed in a natural fold of skin (the ’smile’ incision). After the skin is entered, the
incision is rapidly carried through subcutaneous tissue to the fascia, which is then nicked on
either side of the midline. The subcutaneous tissue is incised sharply with a scalpel. Once the
fascia is exposed, it is incised transversely with heavy curved Mayo scissors. In the standard
technique, the upper and then the lower fascial edges are next grasped with a heavy toothed
clamp, such as a Kocher, and elevated. Under continuous tension, the fascia is then separated
from the underlying muscles by blunt and sharp dissection. Once the upper and lower fascia
have been dissected free, and any perforating vessel sutured or electrocoagulated, the
underlying rectus abdominus muscles are separated with finger dissection. If the muscles are
adherent, sharp dissection is necessary to separate them. The peritoneum is then opened
sharply in the midline. The initial entry is then widened sharply with fine scissors exposing
intraperitoneal contents.

Joel-Cohen Technique
Joel-Cohen (Joel-Cohen 1977) described a transverse skin incision, which was subsequently
adapted for caesarean sections. This modified incision is placed about 3 cm below the line
joining the anterior superior iliac spines. This incision is higher than the traditional
Pfannenstiel incision. Sharp dissection is minimised. After the skin is cut, the subcutaneous
tissue and the anterior rectus sheath are opened a few centimetres only in the midline. The
rectus sheath incision may be extended laterally by blunt finger dissection
(Wallin 1999) or by pushing laterally with slightly opened scissor tips, deep to the subcutaneous
tissues (Holmgren 1999).The rectus muscles are separated by finger traction. If exceptional
speed is required in the transverse entry, the fascia may be incised in the midline and both the
fascia and subcutaneous tissue are rapidly divided by blunt finger dissection (Joel-Cohen 1977).

The Joel-Cohen incision has several advantages compared to the Pfannenstiel incision. These
include less fever, less pain (and therefore less analgesic requirements), less blood loss,
shorter duration of surgery and shorter hospital stay.

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