A caesarean section is one of the most commonly performed abdominal procedures for women, typically undertaken when the anticipated benefits outweigh the potential risks of vaginal delivery. It may become necessary in conditions such as obstructed labour, abnormal fetal positions, placental complications, or a history of previous caesarean delivery1. Among the techniques used for abdominal entry, the Pfannenstiel and Joel-Cohen transverse incisions are the most frequently applied. Both are horizontal incisions, but they differ in the level at which the incision is made and in the method of tissue dissection. The Joel-Cohen incision is placed slightly higher and relies primarily on blunt dissection through the layers of the abdominal wall. This approach is theoretically associated with reduced nerve fibre damage, less postoperative pain, and quicker access to the uterus. It has been suggested that the technique may result in shorter operative time, reduced blood loss, fewer adhesions, faster return of bowel function, and reduced duration of postoperative recovery.2 However, while several clinical trials have demonstrated favourable outcomes with the Joel-Cohen method, other studies have shown minimal or no significant difference between the two techniques, leaving the evidence somewhat inconsistent in routine practice3. Caesarean sections may be classified as planned or emergency procedures, with the decision determined by the condition of the mother, the fetus, or both. The indications are often complex and multifactorial, involving fetal well-being, maternal health, or obstetric circumstances that make vaginal delivery unsafe. Although caesarean delivery can be lifesaving, it carries higher costs and a greater likelihood of postoperative complications when compared with normal vaginal birth.4 Such complications may include infection, bleeding, delayed recovery, or the need for additional interventions. Emergency procedures tend to be associated with a higher risk of complications than planned operations, highlighting the importance of optimising surgical technique and operative efficiency5 .Multiple approaches for abdominal entry have been developed over time, and the choice of technique generally depends on the surgeon’s training, experience, and assessment of clinical circumstances. The Pfannenstiel incision, traditionally used in caesarean delivery, involves a curved transverse cut made just above the pubic region6,7. The Joel-Cohen incision, initially developed for gynaecological surgeries, utilises a straight, higher transverse cut, with the deeper layers separated predominantly by finger traction. A modified version of this technique involves opening the peritoneum only after superficial structures have been separated, thereby reducing the risk of injury to underlying organs such as the bladder.8,9 Given the widespread use of both methods, it is important to determine whether one offers meaningful advantages in terms of operative time, blood loss, postoperative pain, oral intake, maternal recovery, or neonatal well-being. This study therefore aims to assess and compare outcomes associated with the modified Joel-Cohen and Pfannenstiel incisions to better understand their relative safety, efficiency, and overall impact on maternal and neonatal health. AIM To compare between joel–cohen incision and pfannenstiel incision for cesarean section.

This prospective comparative study was conducted in the Department of Obstetrics and Gynecology at …..tertiary care hospital over a six-month period from….. Eligible women undergoing lower-segment cesarean section were randomly allocated into two groups: the Modified Joel-Cohen incision group and the Pfannenstiel incision group. Preoperative assessment included clinical evaluation and routine investigations, followed by surgery using the respective standardized incision techniques. Intraoperative variables such as operative time, incision-to-delivery time, were documented, while postoperative outcomes including pain scores, timing of oral intake, return of bowel activity, complications, and hospital stay were recorded. Neonatal outcomes were assessed using APGAR scoring. Women with term singleton pregnancies who consented to participate were included, whereas those requiring vertical incisions, having placenta accreta spectrum, major systemic comorbidities, multiple gestation, severe fetal anomalies, or previous abdominal surgeries altering tissue planes were excluded. All recorded data were analyzed using appropriate statistical tests to compare maternal and neonatal outcomes between the two incision methods.

TABLE 1: Distribution of cases according to their Age Age Distribution (Years) Group A Group B N (%) N (%) 21-25 63 41.44 67 44.07 26-30 64 42.10 55 36.18 31- 35 18 11.84 21 13.8 >35 7 4.62 9 5.95 Total 152 100 152 100 Most participants in both groups were between 21–30 years of age, forming the predominant age category in the study. The proportions of women aged 31–35 years and above 35 years were comparatively smaller and distributed similarly between Group A and Group B. TABLE 2: Distribution of cases according to their socio economic status as per modified Kuppuswami scale SES Group A Group B N (%) N (%) Upper 2 1.33 1 0.65 Upper middle 15 9.86 9 5.92 Lower middle 65 42.76 55 36.19 Upper lower 41 26.97 48 31.58 Lower 29 19.08 39 25.66 Total 152 100 152 100 The socioeconomic status distribution in both groups showed that most participants belonged to the lower middle and upper lower classeso, with only a small proportion from the upper and upper-middle classes. Overall, the SES pattern was comparable between Group A and Group B, indicating similar socioeconomic backgrounds across the study population. TABLE 3: Distribution of cases according to their Parity Parity Group A Group B N (%) N (%) Primi gravida 92 60.52 98 64.47 Multi gravida 60 39.47 54 35.52 Total 152 100.0 152 100.0 Both groups showed a similar distribution of parity, with primigravida women forming the majority in each group and multigravida women constituting a smaller proportion. Overall, the parity pattern was comparable between Group A and Group B. TABLE 4: Comparison of surgical /operating duration between the two groups Duration of surgery (in minutes) Group A Group B N (%) N (%) 16 – 25 36 23.69 23 15.13 26 – 35 94 61.83 58 38.15 36 - 45 22 14.48 71 46.72 Total 152 100.00 152 100.00 Group A showed shorter operative times, with 36 women in the 16–25 minute range, 94 in the 26–35 minute range, and only 22 taking 36–45 minutes. In contrast, Group B had 23, 58, and 71 women in these respective ranges, indicating longer surgery durations overall. TABLE 5: Comparison of incision to delivery time between two groups Time to deliver baby Group A Group B Mean ± SD 4.2 ± 0.59 6.19 ± 1.38 Range (min.) 2 – 5 2 – 9 The time to deliver the baby was shorter in Group A, with a mean of 4.2 ± 0.59 minutes and a range of 2–5 minutes. In Group B, the mean delivery time was longer at 6.19 ± 1.38 minutes, with a wider range of 2–9 minutes. TABLE 6: Distribution of cases according to Complications Complications Group A Group B N (%) N (%) Wound infection grade 1 12 8 16 10.5 Wound infection grade 2 – 5 5 3.2 8 5.26 Endometritis 1 0 3 1.97 Sepsis 0 0 1 0.65 Febrile morbidity 4 2.6 4 2.6 Urinary tract infection 6 3.9 6 3.9 Need of blood transfusion 2 0 3 0.8 Re laparotomy 0 0 0 0 Both groups showed a generally low complication rate, with Group A having fewer cases of wound infection, endometritis, and need for blood transfusion compared to Group B. Overall, complications were slightly more frequent in Group B, but the pattern remained broadly comparable between the two groups. Table 7: Distribution of cases according to postoperative hospital stay Post op stay Group A Group B N (%) N (%) 5 – 7 days 91 59.8 72 47.34 8 – 10 days 43 28.3 53 34.86 11 – 13 days 18 11.9 27 17.76 Total 152 100.0 152 100.0 Postoperative hospital stay was generally shorter in Group A, with most women discharged within 5–7 days, while Group B had a higher proportion of patients staying beyond 8 days. Overall, longer postoperative stays were more common in Group B compared to Group A.

The age distribution of participants in both groups was broadly similar. Most women in Group A and Group B were between 21–25 years and 26–30 years, forming the largest proportion of the study population. A smaller number of participants fell within the 31–35 years age range in both groups. Women aged above 35 years constituted the least represented category. Overall, the pattern shows that the study population was predominantly composed of younger women. This comparable age distribution helps ensure that age-related factors did not significantly influence the outcome differences between the two groups.This finding aligns with the results reported by Wessam Magdy Abuelghar et al. (2013)10, who found no significant age difference between the Joel-Cohen group (mean age 26.75±3.7 years) and the Pfannenstiel group (mean age 26.53±3.65 years) The socioeconomic status distribution showed a similar pattern across both groups. Most women in Group A and Group B belonged to the lower middle and upper lower categories, forming the largest portion of the study population. A smaller percentage of participants were from the upper middle class in both groups. Only a very small number of women were classified in the upper socioeconomic class. The lower class also contributed a modest proportion of participants in each group. Overall, the SES characteristics of both groups were comparable, ensuring a balanced baseline distribution. The parity distribution was comparable between the two groups. In both Group A and Group B, primigravida women constituted the majority of participants. Multigravida women formed a smaller proportion in each group. This indicates that most women undergoing cesarean section in the study were first-time mothers. The similar distribution of parity across groups helps ensure that parity-related factors did not influence outcome differences. Overall, both groups were well balanced in terms of parity.These findings are consistent with the study by Wessam Magdy Abuelghar et al. (2013)10, which reported comparable mean parity between the Joel-Cohen and Pfannenstiel groups (1±1.2 versus 1±1.5, respectively). The duration of surgery showed a clear difference between the two groups. In Group A, most women had shorter operative times, with 36 patients falling in the 16–25 minute range and 94 in the 26–35 minute range. Only 22 women in this group required 36–45 minutes for the procedure. In Group B, fewer women completed surgery within the shorter intervals, with 23 in the 16–25 minute range and 58 in the 26–35 minute range. A much larger proportion, 71 women, fell into the longest duration range of 36–45 minutes. Overall, surgeries were completed more quickly in Group A compared to Group B.ShyamaPrasad Saha et al. (2012)11 reported a significantly shorter mean total operative time in the modified Joel-Cohen group compared to the Pfannenstiel group (29.81 vs. 32.67 minutes, p<0.0001, 95% CI=2.253 to 3.467). The time required to deliver the baby showed a noticeable difference between the two groups. Group A demonstrated a shorter delivery time, with a mean of 4.2 ± 0.59 minutes and a narrow range of 2–5 minutes. This indicates a quicker and more efficient access to the uterus. In contrast, Group B recorded a longer mean delivery time of 6.19 ± 1.38 minutes, with a wider range extending from 2 to 9 minutes. This reflects greater variability and generally slower delivery in this group. Overall, the findings suggest that Group A had a more rapid incision-to-delivery process compared to Group B.This result is consistent with the findings of Ayatollahi H et al. (2022)12, who reported a mean fetal delivery time of 4.56 ± 0.97 minutes for the Joel-Cohen method and 5.80 ± 1.03 minutes for the Pfannenstiel method (p<0.0001). The distribution of postoperative complications showed a broadly similar pattern in both groups, though Group B had slightly higher frequencies in several categories. In Group A, wound infection grade 1 occurred in 12 patients and grade 2–5 in 5 patients, while Group B reported 16 and 8 cases respectively. Endometritis was seen in only 1 patient in Group A compared to 3 in Group B, and sepsis was reported exclusively in Group B with 1 case. Febrile morbidity and urinary tract infections were identical in both groups, with 4 and 6 cases respectively. The need for blood transfusion was slightly higher in Group B with 3 cases compared to 2 in Group A. No patient in either group required re-laparotomy, indicating that severe complications were rare. Additionally, a meta-analysis by Alireza Olyaeemanesh et al. (2017)13 supports the greater efficacy of the Joel-Cohen technique compared to the transverse Pfannenstiel incision, particularly in reducing postoperative hospital stay (WMD -0.69 days; 95% CI: -1.4 to -0.03 days, p<0.001). These results are comparable to the findings of Dubravko Habek et al. (2020)14, who reported that perioperative and postoperative complications were significantly more frequent with the Pfannenstiel method including perioperative hemorrhage, more frequent adhesions, plastic peritonitis in repeat cesarean sections, and two cases of bladder lesions (p < 0.0005). The postoperative hospital stay showed a clear difference between the two groups. In Group A, the majority of women, 91 in total, were discharged within 5–7 days, indicating a quicker recovery. In contrast, Group B had only 72 women in this shorter stay category. A larger proportion of Group B required 8–10 days of hospitalization, with 53 women compared to 43 in Group A. Similarly, stays of 11–13 days were more common in Group B, with 27 cases versus 18 in Group A. These findings suggest that women in Group A generally recovered more quickly and required shorter postoperative hospitalization. In comparison Ayatollahi H et al. (2022)15 reported a mean hospitalization duration of 2.34 ± 0.47 days in the Pfannenstiel group and 2.18 ± 0.38 days in the Joel-Cohen group, with no significant difference observed between these two groups (p=0.06).

The comparison between the two incision techniques clearly indicates that the Joel-Cohen method provides several clinical advantages over the Pfannenstiel incision. Women in Group A demonstrated shorter operative times, faster incision-to-delivery intervals, and quicker postoperative recovery. Postoperative complications were also slightly lower in Group A, with fewer cases of wound infections, endometritis, and need for blood transfusion. The overall hospital stay was shorter in the Joel-Cohen group, suggesting a smoother recovery period. Baseline characteristics such as age, socioeconomic status, and parity were similar across groups, ensuring that the differences observed were due to the surgical technique rather than demographic variations. These findings are consistent with previously published research, which also highlights reduced morbidity and better efficiency with the Joel-Cohen incision. Taken together, the study supports the conclusion that the Joel-Cohen method is a safer and more efficient option for cesarean delivery.

1. Kerr JMM. The technic of cesarean section with special reference to the lower uterine segment incision. Am J Obstet Gynecol. 1926;12: 729–734. 2. Joel-Cohen S. Abdominal and Vaginal Hysterectomy: New Techniques Based on Times and Motion Studies. London: Heinemann; 1972. 3. Stark M, Finkel AR. Comparison between the Joel-Cohen and Pfannenstiel incisions in cesarean section. Eur J Obstet Gynecol Reprod Biol. 1994;53:121–122 4. Nabhan AF. Long-term outcomes of two different surgical techniques for cesarean. Int J Gynaecol Obstet. 2008;100:69–75. doi: 10.1016/j.ijgo.2007.07.011. 5. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol. 2005 Nov;193(5):1607-17. 6. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019 Feb;133(2):e110-e127. [PubMed] 7. Clapp MA, Barth WH. The Future of Cesarean Delivery Rates in the United States. Clin Obstet Gynecol. 2017 Dec;60(4):829-839. [PubMed] 8. Palmer SK, Zamudio S, Coffin C, Parker S, Stamm E, Moore LG. Quantitative estimation of human uterine artery blood flow and pelvic blood flow redistribution in pregnancy. Obstet Gynecol. 1992 Dec;80(6):1000-6. [PubMed] 9. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011 Jul;118(1):29-38. [PMC free article] [PubMed] 10. Abuelghar WM, El-Bishry G, Emam LH. Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial. J Turk Ger Gynecol Assoc. 2013 Dec 1;14(4):194-200. doi: 10.5152/jtgga.2013.75725. PMID: 24592105; PMCID: PMC3935539 11. Saha SP, Bhattarcharjee N, Das Mahanta S, Naskar A, Bhattacharyya SK. A randomized comparative study on modified Joel-Cohen incision versus Pfannenstiel incision for cesarean section. J Turk Ger Gynecol Assoc. 2013 Mar 1;14(1):28-34. doi: 10.5152/jtgga.2013.07. PMID: 24592067; PMCID: PMC3881734. 12. Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK. Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database Syst Rev. 2014 Dec 05;(12):CD009516. [PubMed] 13. Olyaeemanesh A, Bavandpour E, Mobinizadeh M, Ashrafinia M, Bavandpour M, Nouhi M. Comparison of the Joel-Cohen-based technique and the transverse Pfannenstiel for caesarean section for safety and effectiveness: A systematic review and meta-analysis. Med J Islam Repub Iran. 2017 Sep 4;31:54. doi: 10.14196/mjiri.31.54. PMID: 29445683; PMCID: PMC5804473. 14. Habek D, Cerovac A, Luetić A, Marton I, Prka M, Kulaš T, Ujević B. Modified Stark's (Misgav Ladach) caesarean section: 15 - year experience of the own techniques of caesarean section. Eur J Obstet Gynecol Reprod Biol. 2020 Apr;247:90-93. doi: 10.1016/j.ejogrb.2020.02.026. Epub 2020 Feb 14. PMID: 32087422. 15. Ayatollahi H, Bahadori F, Jahangard S, et al. Comparison of Pfannenstiel & Joel Cohen Cesarean Section Technique in Pregnant Women Referred to Mahzad Hospital. J Gynecol 2022, 7(3): 000235