Modified Joel-Cohen technique for caesarean delivery
Correspondence: Dr G. Wallin, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, S-416 85 Gothenburg, Sweden.
Objective To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial.
Design A prospective controlled trial.
Setting Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden.
Participants Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (n= 36) or Pfannenstiel technique (n= 36).
Main outcome measures Blood loss during surgery and operating time.
Results based on new knowledge, would be beneficial. The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (P= 0.026). The proportion of women with 2 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229,95% CI 0.082–0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (P < 0.001). The proportion of women with 2 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI Conclusions We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intra 0.000–0.026).
Conclusions We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intra-operative blood loss and operating time compared with the Pfannenstiel technique.
When performing caesarean delivery, the Pfannenstiel incision1 is the method of choice in many hospitals. The method includes sharp dissection of the subcutaneous layer and the anterior rectus sheath. A lower uterine segment transverse incision is most commonly performed, described by Kerr2 in 1926. After the baby is born, the placenta is generally removed by insertion of the obstetrician's hand and the incision is sutured in two separate layers. In addition to the fascia, the visceral and parietal layers of the peritoneum as well as the subcutaneous layer are usually sutured. Different suturing techniques, such as staples, continuous intracutaneous sutures or single sutures are used for skin closure. Pfannenstiel incision, when extended into the external and oblique muscles, may injure the iliohypogastric and ilioinguinal nerves3. Several studies have shown fewer complications if the hand is not inserted into the uterus for removal of the placenta compared with the more common practice of shearing the placenta with the inserted hand4–6.
Animal studies7,8 have demonstrated that the peritoneum heals rapidly with fewer signs of fat necrosis, fibrosis and adhesions when left unsutured and clinical studies9,10 have also implied that peritoneal closure is not beneficial compared with nonclosure. When incorporating new knowledge, modification of several steps might be beneficial11. The aim of this study was to elucidate whether an alternative operating method based on new knowledge would be more advantageous, especially regarding operating time and blood loss during surgery.
Seventy-two pregnant women, who were to undergo elective caesarean delivery and who had no history of lower abdominal surgery, were randomly assigned to modified Joel-Cohen technique (study group) and Pfannenstiel technique (control group). The randomisation was by computer-generated, sealed envelopes that were opened by the physician just before surgery, and the results of the randomisation were known only to the single obstetrician (O. F.) who performed all surgery. The envelopes were balanced in four blocks of 18 operations in each block. Using such large blocks diminished the risk that the operator could guess the next treatment allocation. Neither the physicians at the department, the nursing staff nor the women themselves were aware of the randomisation results.
The wound was dressed pre-operatively in plastic drapes in which drainage pockets were incorporated for collecting all fluids. By the end of the operation, the operating sponges were wrung out before the pockets were evacuated into the suction bottle. The blood fraction of the blood-amniotic fluid mixture in the suction bottle was estimated, comparing the haemoglobin concentration with the haemoglobin concentration in the patient's blood. The blood-amniotic fluid mixture was heparinised to prevent clotting. The individual providing anaesthesia recorded the duration of surgery, as well as the volume of fluids given intravenously and blood transfusion, if given. The women scored their post-operative pain every three hours, when awake, on a ten centimetre visual analogue scale. To detect signs of early infection, body temperature was registered daily and C-reactive protein was analysed in blood on the third post-operative day. The post-operative hospital stay was defined as the duration from the day of surgery to the day of discharge.
On the third post-operative day the wound was inspected by another obstetrician (G. W.), who was unaware of the operating method used. Signs of subcutaneous blood effusion, wound disruption, infection and tenderness during palpation were noted, and a sensitivity test of the skin on the lower abdomen was performed, following a detailed protocol. The same procedure was repeated five weeks post-operatively during a visit to the hospital. Eight months post-operatively a questionnaire was sent out, including questions about remembered post-operative and present discomfort. The women also performed a self-assessment, including pain from pressure, sensitivity and appearance, all scored on a ten centimetre scale. The same obstetrician (G. W.) conducted all post-operative clinical examinations and processed the questionnaires. He also assembled all data and first received the randomisation list when the whole study was completed.
Written informed consent, as approved by the ethics committee at Gothenburg University, was obtained from each participant.
Women in both groups scrubbed their abdomens the evening before surgery with a 4% chlorhexidine sponge for at least two minutes just before showering. The same procedure was repeated the next morning. Before surgery the pubic hair was removed from the operative field using a disposable razor and the abdomen was scrubbed with a solution of 0.5% chlorhexidine in alcohol. A urinary catheter was introduced before surgery and removed the same evening. The women received five units of oxytocin intravenously as the cord was clamped. No patient received prophylactic antibiotics. The incision was dressed with a sterile bandage that was removed on the second post-operative day.
Before surgery the women received a spinal blockade with 2.3–2.7 mL of hyperbaric bupivacaine (5 mg/mL), together with 0.1 mL morphine hydrochloride (2 mg/mL), the latter for post-operative pain relief.
The Pfannenstiel technique was performed as the standard procedure in our department. However, the skin incision was placed three cm higher than originally described by Pfannenstiel1. In the modified Joel-Cohen technique12 the skin incision was placed at the same level as described above but avoiding the subcutaneous layer. The subcutaneous tissue was incised only in the three most medial centimetres, while the lateral tissue was separated manually. From this point, the abdomen was opened as described in Table 1. A 3 cm transverse incision was performed in the uterine isthmus, intended to penetrate most of the myometrial layer sharply, sparing the deepest fibres closest to the cavity which were subsequently opened with the blunt end of the scalpel to avoid fetal injury13. The incision was then extended laterally by two fingers. After the baby was extracted the placenta was delivered spontaneously, if necessary with gentle external compression of the uterus. The hysterotomy was closed by five to seven single stitches in one layer using O suture. The visceral and parietal layers of the peritoneum were left open while the fascia was closed by single 0 stitches. The subcutaneous tissue was left unsutured and the skin was sewn with a 3–0 intracu-taneous continuous suture. All suture material, in both the Pfannenstiel and study group, was resorbable braided polyglycolic acid (Dexon 11, Davis and Geck, Wayne, New Jersey, USA).
Table 1. Operative steps.
|Subcutis layer||Incised||Incised and bluntly divided|
|Fascia||Transversely incised 15 cm||Transversely incised 3 cm, divided bluntly|
| ||Sharply separated from muscles||Not separated from muscles|
|Parietal peritoneum||Sharply opened in vertical direction||Incised, bluntly opened in transverse direction|
|Visceral peritoneum||Sharply opened||Sharply and bluntly opened|
|Uterotomy||Sharply opened||Sharply opened in the superficial layers, deeper layers opened and extended bluntly|
|Extraction of placenta||With insertion of hand||Spontaneously|
|Uterotomy||Closed by interrupted sutures||Closed by interrupted sutures|
|Visceral peritoneum||Closed by continuous suture||Not sutured|
|Parietal peritoneum||Closed by continuous sutured||Not sutured|
|Fascia||Closed by interrupted sutures||Closed by interrupted sutures|
Before beginning the study, a power analysis was performed, indicating that 3 1 women would be required in each study arm to demonstrate an intra-operative blood loss reduction from 500 to 375 mL with a standard deviation of 125 mL. This yields a level of statistical significance of < 0.01 with a power of 80%. The estimated reduction of intra-operative blood loss was based on a minor pilot study. Continuous data were analysed with a nonparametric test (Mann-Whitney U test), and data were presented as median [25th, 75th centiles]. Categorical data were analysed with Fisher's exact test (two-tailed). P values < 0.05 indicated a significant difference. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for categorical data.
All women who were asked to take part in the study accepted. The dropout rate was nil during hospital stay, one patient in the study group at discharge, and three at the visit after five weeks (one in the study group, two in the Pfannenstiel group). All women answered the questionnaire at eight months.
The two groups were comparable in terms of age, gestational age and panty and indications for elective caesarean (Table 2). All but seven patients received a spinal blockade with bupivacaine and morphine hydrochloride. One woman in the Pfannenstiel group received the bupivacaine with no added opioid because of previous history of hyper-sensitivity. Four women in the Pfannenstiel group and two women in the study group who preferred not to be awake during surgery received general anaesthesia (Table 2). The median operating time was 20 min in the study group compared with 28 min in the Pfannenstiel group (P < 0.001) (Table 3). The median estimated blood loss was 250mL and 400mL in the study group and the Pfannenstiel group, respectively (P= 0.026, Table 3). No patient received blood transfusion pre- or post-operatively. Sixteen women in the study group, compared with 21 in the Pfannenstiel group scored more than three at any time on a ten centimetre visual analogue scale [P = 0.35, OR 0.57 (0.23–1.45)]. Four women in the study group compared with six women in the Pfannenstiel group needed opioid medication, in addition to that given in the spinal blockade, during the hospital stay. One woman in the study group compared with two in the Pfannenstiel group had a temperature exceeding 38°C at least once. There were no significant differences regarding pain during palpation, wound disruption, haematoma, infection, or sensitivity to light touch, cold or pinprick.
Table 2. Characteristics of women in randomised trial. Values are given as mean (SD) or n
|Age (years)||30.8 (4.7)||29.9 (4.4)|
|Gestational age (weeks)||38.5 (1.4)||38.2 (1.1)|
| Breech presentation||10||6|
| Previous dystocia||2||1|
| Bupivacaine + morphine||34||31|
Table 3. Operative characteristics of women in trial. Values are given as median [25th, 75th centiles) or n. Study group.
|Duration of operation||20 [17.5,20]||28 [25,32]||< 0.001|| |
| ≤ 25 min||1136||33/36||< 0.001||0.003 (0.000–0.026)|
|Operative blood loss||250 [179,500]||400 1300,6941||0.026|| |
| ≤ 300 mL||16/36||28/36||0.007||0.229 (0.082–0.637)|
|Iv fluids||2000 [1700,2300]||2100 [1850,27751||0.084|| |
| ≤ 2500 mL||6/36||14/36||0.064||0.314 (0.1044947)|
|Blood effusion||16/35*||7/36||0.023||3.489 (1.209–10.069)|
|Haemoglobin concentration (g/dL)|
| Before surgery||12.5 [11.5,13.0]||12.3 [11.6,13.1]||0.697|| |
| 3 days after surgery||10.8 [10.3.11.8]||10.9 [10.0,11.9]||0.576|| |
| 5 weeks after surgery||13.2 [12.5,13.7]||13.0 [12.7,13.8]||0.713|| |
|C-reactive protein||48.5 [441.5,61.0]||52.0 [33.5,76.5]||0.748|| |
| ≤ 50 mg/mL||17/36||20136||0.638||0.716(0.283–1.810)|
|Hospital stay||5 [4,6]||5 [4,6.5]||0.458|| |
| ≤ 6 days||10136||16/36||0.220||0.481 (0.180–1.283)|
At five weeks there were no significant differences in the wounds, either in terms of appearance or in the results of any of the above-mentioned tests. The total number of women treated with antibiotics for wound infections during the hospital stay and up to the fifth post-operative week was one in the study group and one in the Pfannenstiel group, respectively. One additional patient received antibiotics for endometritis in the study group. Nine compared with 12 women in the study group and in the Pfannenstiel group, respectively, had taken oral iron medication.
The results from the questionnaire answered at eight months are shown in Table 4.
Table 4. Self assessment on a ten centimetre visual analogue scale showing the proportion of women scoring above a certain level. Values are given as n (%).
| ≥3 cm||14 (39)||18 (50)||0.636 (0.250–1.622)|
|Discomfort, compared to expected level|
| ≥ 3 cm||9 (25)||10 (28)||0.867 (0.303–2.475)|
| ≥ 2cm||6 (17)||12 (34)||0.400 (0.131–1.223)|
| ≥ 2cm||7 (19)||11 (31)||0.549 (0.185–1.629)|
|Pain from pressure|
| ≥1 cm||3 (8.3)||6 (17)||0.455 (0.104–1.980)|
|Perception of light touch|
| ≥9cm||20 (56)||16 (44)||1.562 (0.617–3.959)|
| ≥ 9 cm||26 (72)||24 (67)||1.300 (0.475–3.555)|
The present study is a controlled prospective study involving only one surgeon. This design guarantees a highly standardised operating technique. The randomised prospective design lowers the risk of bias regarding background factors. One major finding of the present study was that the new surgical technique resulted in lower blood loss during surgery compared with Pfannenstiel technique. The intra-operative blood loss was measured using a sensitive sampling method. However, there was no difference in post-operative haemoglobin concentration (Table 3) between the two groups. One other major finding of the present study was that the new surgical technique resulted in reduced operating time. Stark and Finkel4, in a retrospective study, also found an operating time reduction when the abdomen was opened by Joel-Cohen incision. Pietrantoni et al.15 used a standard Pfannenstiel technique in a quasi-randomised study but left the peritoneal layers open to spontaneous healing in the study group in contrast to the control group. This also resulted in some-what shorter operating times without other differences in outcome. In a recent prospective study, Irion et al.9 presented a reduction in operating time as well as a shorter time for return of bowel sounds when the visceral and parietal peritoneum were left unsutured compared with when they were sutured.
In the present study, as in clinical practice, we have chosen an incision level between the original low Pfannenstiel incision and the Joel-Cohen incision. We found no technical disadvantage of incising at a lower level than that described by Joel-Cohen12. Today, many women are not inclined to have the abdominal skin disfigured by a highly positioned scar. Our results indicate that most women are very satisfied with the appearance of the scar as they scored 9.5 vs 9.8 (medians) on a ten centimetre visual analogue scale in the study group and the Pfannenstiel group, respectively. This is approximately the same result as for low transverse scar in a study dedicated to cosmetic outcome after caesarean delivery16. The women in that report scored 8.9 for a low transverse scar with intracutaneous suturing, compared with 6.6 for lower midline incision suturing with percutaneous suture.
In the present study only women scheduled for elective caesarean sections were included. The objective, as well as of having only one obstetrician performing the surgery and only one other obstetrician performing all the follow up, was to standardise the study conditions. In order to control study conditions, only women with no former lower abdominal surgery were included. When performing caesarean section the second or third time, adhesions in different layers will increase the operating time somewhat. In some cases it is necessary to use scissors to enlarge the fasciae opening.
In the study group the placenta was delivered spontaneously, with gentle external compression of the uterus, if necessary. Compared with manual shearing of the placenta from its attachment at the decidua basalis, this method is superior with regard to operative blood loss6 and postpartum endometritis5,6. When the hand is not inserted into the uterine cavity, a lower frequency of endometritis was observed5,6, while change of gloves before inserting the hand had no effect on the rate of infection5. The observed reduction of blood loss in the study group in the present study might be a result of spontaneous delivery of the placenta, different surgical technique or shorter operating time.
The objection might arise that it would have been better not to introduce the difference in extracting the placenta since this is independent of incision and suturing techniques. However, the aim of the study was to evaluate whether a series of steps with individual potential advantages, might be beneficial if used together. Manual shearing of the placenta had been our usual technique previously.
Kerr2 recommended a two-layer closure of the uterine incision. As a one-layer closure might save operating time and introduce less foreign material, this concept was used in the study group in our trial. In a study including 906 women Hauth et al.17 found that one-layer closure was equally effective as two-layer closure in terms of haemostasis and resulted in shorter operating time. A retrospective study of subsequent labour in women with previous caesarean delivery including one- or two-layer uterine closure did not reveal any increased risk of scar separation or uterine rupture in the one-layer group18.
Accumulated animal data show that reapproximation of peritoneal edges is unnecessary and results in increased tissue necrosis and foreign body tissue reactions that may impair healing. This foreign body reaction may actually increase the risk of adhesion formation7,8. Leaving the parietal peritoneum15, visceral peritoneum19 or both the visceral and parietal peritoneum open9,20,21, during caesarean delivery resulted in shorter operating time15,19,21, shorter time of paralytic ileus9,20 and lower febrile and infectious morbidity19,21. In our study none of the peritoneal layers were sutured in the study group. We did not register any suspected complications that may be attributed to this fact nor did we notice any of the advantages mentioned in the quoted studies.
An interrupted resorbable O suture was chosen for closure of the fascia. Interrupted suturing was chosen to decrease the risk of nerve entrapment syndrome resulting from suturing in the area of the iliohypogastric nerve3. Published reports22–24 comparing continuous or interrupted suturing technique mainly involve lower midline incision and show conflicting results regarding strength and frequency of dehiscence.
We chose not to suture the subcutaneous fat in the study group in order to place as few sutures as possible, as subcutaneous suture material may predispose to infection. Blood effusions in the subcutis were more common in the study group in our study (Table 3). This is supposed to be due to facilitated transport of blood and fluid from the abdomen by the end of surgery because of absence of the suturing in the peritoneal and subcutis layers. However, no increase in haematomas or other wound complications was found. Due to the relatively small size of the study, no conclusion can be made regarding whether or not subcutaneous suturing should be abandoned25–28.
To reapproximate the skin edges, intracutaneous resorbable 3–0 sutures were used in both groups. This gives an excellent cosmetic result16 while eliminating the risk of nickel hyper sensitivity reactions that some steel staples may cause. Another advantage of this closure technique, compared with staples or percutaneous sutures, is that an extra visit to the clinic for removal of staples or sutures is unnecessary. Stark and Finkel11 have proposed the use of only a few, widely spread silk stitches in the skin, but no results have been presented regarding the final healing of the wounds or the women's satisfaction with wound appearance.
The primary outcome of the present study is that caesarean delivery performed with the modified Joel-Cohen technique reduces operating time and blood loss during surgery. The operations in this study were performed by a very experienced senior obstetrician which makes the operating times short in both groups. In clinical practice many caesarean sections are performed not by senior obstetricians, but by residents. The operating time might then be considerably longer and blood loss during surgery might be greater, and it remains to be seen whether the advantages found in this study are sustained.
A study of this size does not have enough power to show a difference in the frequency of wound infections or other maternal morbidity during caesarean delivery using the described technique, as the rate of maternal morbidity was low in both groups.
The study was supported by grants from Bohus County Health Authority. We thank Associate Professor L.-Å. Mattsson for constructive criticism regarding the manuscript.