Clinical overview
Caesarean section (CS) is the most commonly performed major operation in South African obstetrics and, in many district and regional hospitals, the single highest-volume theatre procedure. As a registrar you will do hundreds, frequently at night, often as the most senior obstetric hand in the building, and sometimes on a woman who is bleeding, septic, or whose fetus is acidotic on the table. "Safe technique" therefore means far more than knowing the steps: it means a reproducible, evidence-anchored sequence that protects mother and baby, minimises blood loss and infection, and is teachable to the next person on call. CS is not a benign operation — it carries maternal mortality and morbidity well above vaginal birth, and in South Africa caesarean delivery is repeatedly implicated in the Saving Mothers report as a site of avoidable death, principally through obstetric haemorrhage, anaesthetic complications, and sepsis.
The objective here is descriptive: you must be able to walk through a safe CS from decision through closure, justify each step against evidence where it exists, and — explicitly named in the objective — describe the various skin incisions and when each is chosen. The chapter is structured to let you recite the operation as a coherent narrative, the way you would teach a junior in the scrub room, while signposting the few steps that genuinely change outcomes. Related perioperative and procedural detail sits in ERAS principles, Safe use of surgical instruments, Electrosurgery safety and Perioperative fluids; the haemorrhage and rupture sequelae are covered in Postpartum haemorrhage, Uterine rupture and VBAC.
Core knowledge
Figure F13.1 — Safe CS entry choice map: match the access to the risk — Joel-Cohen / Misgav-Ladach (routine) vs Pfannenstiel vs midline — open in layers with blunt expansion and a low-transverse uterine entry away from the vessels.
Categorising urgency
Decision-to-delivery interval is driven by a shared urgency classification (the RCOG/NICE four-category scheme): Category 1 — immediate threat to the life of woman or fetus (e.g. cord prolapse, scar rupture, sustained fetal bradycardia, abruption with fetal compromise) — aim to deliver as fast as safely possible, conventionally taught as a 30-minute target; Category 2 — maternal or fetal compromise that is not immediately life-threatening; Category 3 — needs early delivery but no compromise; Category 4 — elective, at a time to suit the woman and team. The category determines the anaesthetic (general anaesthesia is sometimes unavoidable for a true Category 1) and how much of the WHO Surgical Safety Checklist can be completed without delaying delivery. The 30-minute figure is a clinical audit standard rather than a hard physiological threshold; do not let chasing the clock force a dangerous general anaesthetic when a rapid spinal is feasible.
Skin incisions (named in the objective)
The choice of abdominal entry is a genuine technical decision with trade-offs in access, cosmesis, strength, and speed.
- Pfannenstiel incision — the default for most caesareans. A transverse, slightly curved incision roughly two fingerbreadths (~2–3 cm) above the pubic symphysis, through skin and subcutaneous fat to the rectus sheath; the sheath is incised transversely and dissected off the rectus muscles superiorly and inferiorly, the muscles separated in the midline, and the peritoneum opened (classically higher up, to stay away from the bladder). Advantages: strong (transverse, along Langer's lines), good cosmesis, less post-operative pain, low dehiscence and incisional-hernia rates. Disadvantage: more sharp/blunt dissection between layers, theoretically more bleeding from perforating vessels, and limited vertical access.
- Joel-Cohen incision — a straight transverse incision sited slightly higher than the Pfannenstiel (about 3 cm below the line joining the anterior superior iliac spines), with the deeper layers opened largely by blunt finger dissection and lateral traction rather than sharp dissection. It is the entry used in the Misgav Ladach method and is favoured by the major surgical-technique evidence (CORONIS, Cochrane) for shorter operating time, less blood loss, less fever and reduced analgesia requirements compared with Pfannenstiel.
- Midline (vertical) sub-umbilical incision — a lower-midline laparotomy. Reserve for situations needing rapid entry or wide access: massive haemorrhage, suspected adhesions or placenta accreta spectrum, very preterm or transverse lie needing a vertical uterine incision, peripartum hysterectomy, or when the abdomen must be explored. Faster and almost bloodless to open, but weaker, more painful, higher hernia and dehiscence risk, poorer cosmesis.
The uterine incision is described separately: the low transverse (lower-segment) incision is standard — less bleeding, better healing, lower subsequent rupture risk, and it permits trial of labour later (VBAC). A classical (upper-segment vertical) or low-vertical (De Lee) uterine incision is reserved for a poorly formed lower segment (extreme prematurity), transverse lie with back down, dense lower-segment adhesions/fibroids, anterior placenta praevia/accreta, or some perimortem caesareans — and it commits the woman to elective repeat CS because of the rupture risk.