Home > Green Journal, Gynecology, Journal Articles, Obstetrics > Green Journal – Vertical vs Transverse Skin Incisions for Emergent Cesarean

Green Journal – Vertical vs Transverse Skin Incisions for Emergent Cesarean

Junes’s Green Journal had an interesting article on vertical versus transverse skin incisions for emergent cesarean deliveries that seemed worth some comment.

The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes.  This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.

The study looked at 3,525 emergent cesarean deliveries performed in 1999 and 2000 at the study centers.  Of these deliveries 2,498 (70.9%) were done with transverse abdominal incisions and 1,027 (29.1%) were done with vertical incisions.

The two groups were similar in age, but differed in BMI, with patients having vertical incisions being more likely to have larger BMIs (31.5 v 32.4, p = 0.02).  There was also significant differences in rare between groups, with vertical incision patients being more likely to be Hispanic than transverse incision patients (Transverse – white 37%  AA 47%  Hispanic 11%; Vertical 16% white 41% AA  Hispanic 40%, p < 0.001.)  Transverse incision patients were also more likely to be nulliparous (49% vs 43% p = 0.002.)

The groups also differed in number with previous cesarean deliveries, with the vertical incision group being somewhat more likely to have had previous cesareans.

Surgeries with vertical incisions were done more quickly than transverse incisions, with median incision-to-delivery intervals of 5.5 minutes with transverse versus only 3.5 for vertical for primaries, and 6.8 minutes vs 5.1 minutes for repeat cesareans.   The incision to closure interval was longer for vertical incisions, 50 minutes vs 46 minutes in transverse incisions in primary sections, 67 vs 56 minutes in repeat cesareans.

Contrary to what one might think, there was no differences in maternal injury with the two groups, with intraoperative injury occurring in 0.7% of each group.  Postpartum endometritis was more common in the vertical group 15% vs 11%, p = 0.006.  Wound infection, hematoma, ileus were similar between groups.  The vertical group had more need for transfusion, 7% vs 5%, p = 0.01.

Low umbilical artery pH < 7.0 was  more common in the vertical group 10% vs 7%, p = 0.02.  Frequency of hypoxic encephalopathy was greater in the vertical group 3% vs 1%, p < 0.001. Babies born via vertical incision were more likely to need intubation in the delivery room, 17% vs 13% p = 0.001. There were no differences in  need for infant CPR, neonatal death, or 5 minute apgar scores (though there was as trend towards lower apgars for the vertical group, 5% vs 4% p = 0.06.)

OK – so what does this all mean?

This is what I get out of it:

1. In a very large set of data, gathered at teaching centers where residents are doing the operating, surgeons seem to be able to get babies out a bit quicker with vertical incisions than with transverse incisions.

2. Contrary to what I would have thought, there did not seem to be a greater number of maternal injuries with the vertical incisions.  This is surprising to me as the worst bladder injury I have seen came from an overzealous vertical incision during a crash cesarean.  Perhaps I am just mentally scarred from one event.

3. The fetal outcomes data is not worthwhile.  The data is quite biased by the indication for the crash cesareans.   People already have a pre-existing thought that a vertical incision can lead to a quicker delivery, and so it makes sense that they would have done more verticals in more severe cases where it was felt that every second counted.  As such, it is not surprising that the vertical incision babies had worse gases, were more likely to be intubated, and had a higher frequency of neonatal encephalopathy.  To me, this says nothing about the effect of the incision, especially given that the group with the worse outcomes had quicker delivery times.

But here’s the thing:  It seems very odd to me to aggregate some huge dataset to try to describe something that is so individual from surgeon to surgeon.  Each surgeon has a pretty good idea of what they can do quicker, and a large data set that describes thousands of different surgeons doesn’t really imply anything about each individual.   I can say without question that in a primary section I can reliably deliver an infant through a transverse skin incision in less than 60 seconds.  Perhaps I could do it a little faster with a vertical, but to me those few seconds don’t seem worth it.  Does this mean that everybody else should do the same thing as I?  Of course not – we are all different surgeons and some people might be able to do a vertical much quicker than they could do a transverse incision.   There are factors that might change our mind for each patient as well, such as previous surgeries, or even previous vertical incisions.  But ultimately, each surgeon knows more about their individual performance than any paper can tell them about themselves.  And for that reason, I don’t find this data all that helpful.

To me, the thing that will be quickest is usually what one knows the best.   Most gynecologists have done hundreds if not thousands of transverse entries, and if need be they can do them very quickly.  Most gynecologists, especially residents (who were described in this case), have not done as many vertical incisions, and likely can accelerate a technique they already know better than they can try to rush something they are not as comfortable with.  That being said, the data did show than on the average (or on the median), verticals were faster.  Go figure.

So what do you all do?

Comparison of transverse and vertical skin incision for emergency cesarean delivery.   Wylie BJ, Gilbert S, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Miodovnik M, O’Sullivan MJ, Sibai BM, Langer O; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Obstet Gynecol. 2010 Jun;115(6):1134-40.

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  1. July 9, 2010 at 3:33 am | #1

    Great review Nicholas. I concur that the authors likely missed the mark in terms of what most clinicians would want to know. Indeed the two minute difference would tend to lead me to continue to perform stat surgery with the approach that I found most comfortable in a given clinical situation.

    As an educator, I would also stress the importance of having residents learn to become adept at both surgical approaches so that they can ultimately decide for themselves which approach works best for them.

  2. JMT
    July 9, 2010 at 4:11 am | #2

    I’d be curious about the implications for repeat cesareans. Once a woman has had one type, is it better or worse to do the same type again? For the repeats in this study, which type did they have previously?

  3. J Oliver Daly
    July 9, 2010 at 5:02 pm | #3

    I think what this article serves to demonstrate is that vertical incisions do not significantly improve neonatal outcome, and therefore reduces indecision over which type of incision to employ in the mind of those performing emergency C/Ss.

    Despite what this study says, there is no doubt that vertical incisions are a more morbid procedure both initially and in the long term:
    – In Australia, length of stay post transverse incision C/S is 3 nights, and vertical incisions would incur at least another nights stay because of the morbidity of the procedure
    – Mobility and post-operative pain is greater with vertical incisions.
    – Good technique is critical and complexity greater of closing a vertical incision. If a good mass closure technique is not employed, dehiscence creates a far greater problem. And given that wound infection rates in emergency C/S and particularly crash C/Ss are greater, the consequences of a wound infection are greater for a vertcal incision. We also know that transverse incisions have a very low hernia rate compared with vertical incisions.
    – In the longer term, adhesion rates are significantly greater with a vertical versus transverse incision having consequences for the risks of future abdominal surgery

    The argument for saying that residents should learn to be adept at both techniques is good in theory, but in practice we are doing far far less vertical incision because of the associated patient morbidity, and patient wellbeing should come first over training. Therefore the current generation of trainees will inevitably become less comfortable with vertical incisions, and as said in an emergency you want to go with what you’re most comfortable and experienced with.

    So the conclusion I draw is that given the absence of significant benefit for the foetus/neonate and the known post-operative problems of vertical incisions, , we should feel secure that by performing transverse incision we are not causing significant risk to the foetus. I also have never worked with an obstetrician who routinely performed vertical incisions and would prefer that method of entry ( unless there were other non-obstetric factors, e.g other known abdominal pathology )

  4. July 10, 2010 at 11:08 am | #4

    Thanks for the comments!

    >> I’d be curious about the implications for repeat cesareans. Once a woman has had one type, is it better or worse to do the same type again? For the repeats in this study, which type did they have previously?

    If someone already has a vertical incision on the skin, most people would cut vertically on the skin again, just so there isn’t two scars. A vertical scar is ugly, an “anchor” is even worse. I don’t think the study indicated what type of incision women had in their initial cesareans, in cases of repeats.

    Its important to point out that the skin incision does not have anything to do with the uterine incision. Term cesareans are almost always done with transverse uterine incisions, even when the skin incision is vertical. Some cultures do a lot of vertical skins incisions.

    Almost every patient I see who had a cesarean done in Mexico has a vertical skin incision.

  5. J Oliver Daly
    July 11, 2010 at 11:34 pm | #5

    Your point about the majority of Mexicans having vertical incisions is quite interesting. This is also quite common in those emigrating to Australia from mainland China, suggesting that there is a fairly significant medico-ethnic cultural determinant for choice of incision.

    One of the other issues this also creates is the uncertainity in the minds of clinicians over the type of uterine incision that was used, if the patient has a vertical skin incision. This uncertainity is often due to a lack of access to documentation particularly in immigrants. This ofcoures has implications for the suitability for VBAC

    Thanks for the discussion…

  6. July 12, 2010 at 1:40 pm | #6

    Oliver – There actually are some data on uterine rupture rates in women with unknown scars, showing low rupture rates < 1% when the previous cesarean was at term and done for an indication not likely to lead to a vertical hysterotomy. Of course this data does not suggest that every one of these women is low risk, only that mathematically one can not identify an increased risk as the majority of them have low risk scars.

    If I have a woman who had a cesarean in another country and cannot get an op note, I am generally OK with a VBAC as long as the previous cesarean was done at term.

    That being said, I've heard so many bogus excuses on why an op note could not be obtained. I have occasionally had to remind a resident that they have fax machines and keep medical records just about everywhere in the world, even in underdeveloped countries.

  7. July 16, 2010 at 6:44 pm | #7

    Its a pain for cesarean always. Delivery of the neonate via emergency cesarean section occurs more quickly with a vertical skin incision than a transverse skin incision, but this is not associated with improved neonatal outcomes. The study has shown that it might be a very easy method but still a pain.

  8. July 31, 2010 at 6:51 am | #8

    I am mostly struck by how slow all the numbers are. In routine low transverse CS’s, my skin to delivery times are usually around 3 min, and in rare emergent CS’s 1-2 minutes. Of course with dense scar tissue or morbidly obese patients , it may take a bit longer, but 5 minutes would be fairly extreme in a routine case.
    Closure times rarely exceed 15 minutes.
    What are these OB’s doing that takes so long? I feel that I am very careful in my approach and do not hurry, and have never had to return to the OR or had any serious wound issues.

    • July 31, 2010 at 7:06 am | #9

      They are slow, but it is all in academic centers with residents operating. I’d have to go back and look but I think average BMIs were pretty high as well.

  9. Courtney
    June 3, 2011 at 7:03 am | #10

    Dr Fogelson – you point to academic centers having residents perform the emergency sections for the increase in delivery time. Are residents more readily available to do the surgery which means that the length of time to do the procedure is longer but the decision to incision time is shorter? I know that training new doctors is very important, but it would seem to me that in true emergencies it may be suboptimal for slower less experienced surgeons to be performing c sections.

    • June 3, 2011 at 8:01 am | #11

      That’s a great question. I think being in a fully staffed academic center definitely lets one react quicker to situations that one could in a private practice situation. This is one of the reasons we are able to watch bad strips in the academic setting that others would deliver.

      The question of allowing residents to operate is an important one. The responsibility residents are given is graduated to their skill and experience. By the time residents are in their fourth year, they typically can do a cesarean quite quickly. In some cases an attending might be able to go faster, but in others not. Ultimately though, I have to let residents practice the skills they will need when they go on to be unsupervised. The important thing for me as a teaching physician is to take over when the situation is getting too complex for the residents involved. Sometimes I do that too much, to the residents’ chagrin, but ultimately I would rather err on the side of too much attending intervention than too little.

      I think the other important issue here is that while there are some cesareans that are ‘emergent’, there is only a small subset of those where every second counts. Residents are not going to be doing the latter until they have demonstrated significant skill in non-emergent cesareans.

  10. July 10, 2011 at 11:03 pm | #12

    Whatever it may be, if we talk about C-section, it scares me. Simply the thought of undergoing an operation is unbearable! And, the thing is, I might be on C-section in 2 weeks, my baby is in a transverse position, that is why. Whew!

  11. November 7, 2011 at 9:29 pm | #13

    I am very happy to read this article..thanks for giving us this useful information.

  12. Michelle
    November 15, 2011 at 4:58 am | #14

    I’m curious, does this dataset include those situations where there are previas and positional variations? My CS took couple of minutes to deliver, but my doctor discussed this with me prior to surgery because I had an anterior previa with transverse lie. In my case we agreed on a transverse skin incision, and vertical uterine to accommodate the issues. (We’re fine, by the way!)

    The vertical incision really helped make space, and while it excludes me from ever VBACing (I don’t really care) it made for a safer and faster delivery.

  13. SLT-A65
    November 16, 2011 at 7:26 am | #15

    Ciao, davvero interessante, grazie

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