Comparative Evaluation of Perioperative Outcomes Between Modified Misgav-Ladach Technique and Pfannenstiel Technique in Cesarean Section: A Quasi-Experimental Study
DOI:
https://doi.org/10.52206/jsmc.2026.16.2.1408Abstract
Background: Cesarean section is one of the most commonly performed surgical procedures worldwide, with increasing rates across both developed and developing countries. Advances in surgical techniques aim to improve operative efficiency, reduce complications, and enhance maternal outcomes. The Modified Misgav-Ladach (MML) technique has been proposed as a minimally invasive alternative to the conventional Pfannenstiel approach, potentially offering reduced operative time and blood loss.
Objective: To compare perioperative outcomes, specifically hemoglobin decline and skin incision to cord clamp time, between the Modified Misgav-Ladach technique and the Pfannenstiel technique in cesarean section.
Methodology: This quasi-experimental study was conducted in the Department of Obstetrics and Gynaecology, District Headquarters Hospital, Rawalpindi, over a six-month period (March–August 2024). A total of 60 women meeting inclusion criteria were allocated into two groups: Group A (Pfannenstiel technique, n=30) and Group B (Modified Misgav-Ladach technique, n=30). All procedures were performed under spinal anesthesia with standardized perioperative management. Primary outcomes included perioperative hemoglobin decline and skin incision to cord clamp time. Data were analyzed using SPSS version 24, and independent sample t-tests were applied, with p≤0.05 considered statistically significant.
Results: The mean postoperative hemoglobin level was significantly lower in Group A (11.33±1.23 g/dL) compared to Group B (12.25±0.98 g/dL) (p=0.002; 95% CI: 0.35–1.49). The mean perioperative hemoglobin decline was also greater in Group A (1.70±0.86 g/dL) than in Group B (1.13±0.91 g/dL) (p=0.016; 95% CI: 0.11–1.03). Additionally, the mean skin incision to cord clamp time was significantly longer in Group A (11.53±2.81 minutes) compared to Group B (4.17±1.29 minutes) (p<0.001; 95% CI: 6.23–8.49).
Conclusion: The Modified Misgav-Ladach technique demonstrated superior operative efficiency and reduced perioperative hemoglobin decline compared to the Pfannenstiel technique.
Keywords: Cesarean section, Hemoglobin decline, Modified Misgav-Ladach technique, Pfannenstiel incision, Perioperative outcomes.
References
Sizear MI, Rashid M. Urgent need to address increasing caesarean section rates in lower-middle-income countries like Bangladesh. Front. Glob. Womens Health.2024;5. https://doi.org/10.3389/fgwh.2024.1365504
Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. 2023 May 18;6(5):e1274. https://doi.org/10.1002/hsr2.1274
Parasiliti M, Vidiri A, Perelli F, Scambia G, Lanzone A, Cavaliere AF. Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical J Matern Fetal Neonatal Med. 2023 Dec;36(2):2284112. https://doi.org/10.1080/14767058.2023.2284112
Jadoon I, Khattak M, Mughal K S. Rising Cesarean Section Rates in Pakistan: Analyzing Frequency and Key Risk Factors in a Tertiary-Care Hospital. Cureus.2024;16(10): e72333. https://doi.org/10.7759/cureus.72333
Sung S, Mikes BA, Martingano DJ. Cesarean Delivery. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 Jan. https://www.ncbi.nlm.nih.gov/books/NBK546707/
Kaya B, Ozay OE, Ozay AC and Tüten A. Can the Pfannenstiel skin incision length be adjusted according to the fetal head during elective cesarean delivery? Front. Surg. 2023;10:1-9. https://doi.org/10.3389/fsurg.2023.1227338
McCardy R. Cohen vs Pfannenstiel cesarean skin incision for body mass index ?35 kg/m²: a randomized controlled trial. Am J Obstet Gynecol MFM. 2024;6(12):101528. https://doi.org/10.1016/j.ajogmf.2024.101528
Gialdini, Celina. Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. eClinicalMedicine, 2024;72: 102632. https://doi.org/10.1016/j.eclinm.2024.102632
Bourdakos NE, Abdulsalam FAM, Macaron MM. Misgav-Ladach or modified Misgav-Ladach versus Pfannenstiel-Kerr methods for cesarean deliveries: A systematic review and meta-analysis. Reprod Female Child Health. 2023; 2: 287-300. https://doi.org/10.1002/rfc2.65
Stark M. The Stark (Misgav Ladach) cesarean delivery—a streamlined surgical technique: development, rationale, and clinical outcomes. American Journal of Obstetrics and Gynecology. 2025,ISSN 0002-9378, https://doi.org/10.1016/j.ajog.2025.07.048
Xavier P, Ayres-De-Campos D, Reynolds A, Guimarães, Costa-Santos C, Patrício B. The modified Misgav-Ladach versus the Pfannenstiel–Kerr technique for cesarean section: a randomized trial. Acta Obstetricia et Gynecologica Scandinavica.2005;84: 878-882. https://doi.org/10.1111/j.0001-6349.2005.00631.x
Mahmud G, Rafiq F, Tabassum A, Tasnim N. Comparative Analysis of Modified MISGAV Ladach and Conventional Caesarean Section. Ann Pak Inst Med Sci. 2013;9(3):153-8.
Rossouw JN, Hall D, Harvey J. Time between skin incision and delivery during cesarean. Int J Gynaecol Obstet. 2013;121(1):82–85. https://doi.org/10.1016/j.ijgo.2012.11.008
Hofmeyr GJ, Mathai M, Shah A, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008 Jan 23;2008(1):CD004662. https://doi.org/10.1002/14651858.CD004662.pub2
Dahlke JD, Mendez-Figueroa H, Maggio L, Sperling JD, Chauhan SP, Rouse DJ. The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees. Obstet Gynecol. 2020 Nov;136(5):972-980. https://doi.org/10.1097/AOG.0000000000004120
Felis S. Caesarean section according to Misgav Ladach. AJMCRR 2023; 2(8): 1-9. https://doi.org/10.58372/2835-6276.1056
Ezechi O, Ezeobi P, Gab?Okafor C, Edet A, Nwokoro C, Akinlade A. Maternal and Fetal Effect of Misgav Ladach Caesarean Section in Nigerian Women: A Randomized Control. Ann Med Health Sci Res. 2014;3(4):577-82. https://doi.org/10.4103/2141-9248.122119
Nankali A, Farajzadeh F, Rezaei M, Malekkhosravi S, Daeichin S. Comparison of the outcomes of traditional and Misgav-Ladach techniques in caesarean section. J Biol Todays World. 2014;3(2):44–48. https://doi.org/10.15412/J.JBTW.01030204
?ahin N, Genc M, Turan GA, Kasap E, Güçlü S. A comparison of 2 cesarean section methods, modified Misgav-Ladach and Pfannenstiel-Kerr: A randomized controlled study. Adv Clin Exp Med. 2018 Mar;27(3):357-361. https://doi.org/10.17219/acem/66215
Belci D, Kos M, Zorici? D, Kuhari? L, Slivar A, Begi?-Razem E, et al. Comparative study of the “Misgav Ladach” and traditional Pfannenstiel surgical techniques for caesarean section. Minerva Ginecol. 2007;59(3):231–240. PMID: 17576402.
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