**6.4 Incision**

The choice of incision is crucial for accessing the abdomen in the surgical management of postpartum hemorrhage. Especially in cases of placental invasion anomalies and complicated bleeding, a vertical incision is recommended to achieve complete and comfortable pelvic exposure. With this incision, dissection of the pelvic sidewall, particularly the vascular structures, can be performed more easily, and vascular

clamping or ligations can be readily carried out. Additionally, preserving the integrity of the placenta is of utmost importance for the surgical management of placental invasion anomalies to prevent sudden bleeding. To achieve this, the fetus is delivered through an incision made from an area without the placenta, facilitated by the vertical incision. In cases of placenta accreta spectrum (PAS), after a vertical incision is made, the fetus is delivered through a fundal incision, ensuring the preservation of placental integrity and protecting the patient from sudden bleeding. In addition to these recommendations, experienced surgeons particularly prefer transverse incision in PAS cases. After entering the abdomen through a transverse incision, the fetus is delivered through a transverse incision just above the termination of the placenta. The remaining parts of the hysterectomy can be completed without compromising placental integrity. This technique can yield advantages such as reduced bleeding and improved cosmetic outcomes. Transverse incisions are also utilized in our clinic. For cases of uterine atony, a transverse incision is recommended. With this incision, procedures such as hysterectomy, arterial ligations, or compression sutures can be easily performed in cases of uterine atony. In situations where sufficient exposure is not achieved with the classic Pfannenstiel incision, relaxation of the rectus abdominis muscles can further facilitate access to the pelvis.
