Cesarean Section

• Skin incision
  • Scalpel or electrocautery
  • Transverse versus vertical incision
  • Size of incision
• Subcutaneous layer
  • Divided with scalpel, electrocautery or bluntly to permit visualization of fascia
• Fascial layer
  • Central incision made sharply and two layers of fascia divided laterally in a sharp or blunt fashion

• Rectus muscle layer
  • Pfannenstiel: Vertical separation
  • Modified Maylard: Sharply divide rectus muscles in transverse fashion if additional exposure is needed
• Peritoneal layer
  • Open bluntly or sharply
  • Open high to avoid bladder
  • Be aware of possible intraperitoneal adhesions
  • Be aware of underlying bowel
  • Ensure adequate exposure

• Bladder flap
  • No conclusive evidence that creation of a bladder flap decreases risk of intraoperative or postoperative complications
• To form bladder flap:
  • Vesicouterine serosa opened superior to the bladder and incision extended laterally
  • Bladder separated bluntly or sharply from the underlying lower uterine segment
  • Bladder blade retractor placed to protect bladder

Uterine Incision

• Low transverse (most common)
• Low vertical
• Mid transverse
• Classical
• Consider:
  • Fetal size and position
  • Development of the lower uterine segment
  • Position of placenta
  • Obstructing adhesions or fibroids

• Low transverse uterine incision
• Most common, preferred to decrease risk of lateral extensions
• To form uterine incision:
  • Use scalpel to begin hysterotomy
  • Can complete uterine entry bluntly with index finger to decrease risk of fetal injury
  • Incision extended bluntly or with bandage scissors: Blunt extension associated with less blood loss1
  • Can bluntly open/extend incision in a transverse manner (as seen on right) or in a cephalocaudal manner
    • Extension in a cephalocaudal manner associated with reduced blood loss and unintended extension 2
  • Stay clear of the uterine vessels found laterally

• Classical incision:
  • Vertical incision through the active segment/fundus
  • Increased blood loss
  • Closed in multiple layers
  • Higher rate of uterine rupture in subsequent pregnancies (4-9%)1
  • Not a candidate for TOLAC after classical cesarean section
• Common indications for classical incision:
  • Preterm breech with undeveloped lower uterine segment
  • Transverse back-down fetal position
  • Adhesions/fibroids obstructing the lower uterine segment
  • Scheduled cesarean hysterectomy
  • Perimortem

Delivery of Fetus

• Amniotomy
  • May opt to deliver “en-caul” in cases of extreme prematurity or maternal infection (i.e., HIV)
• Maneuvers depend on position of fetus or fetuses

Images courtesy of U.S. Department of Health and Human Services.

Delivery of Vertex Fetus

• Fetal head is manually elevated through the hysterotomy
• Fundal pressure can aid the delivery
• Avoid placing pressure on lower  uterine segment to decrease risk of extensions
• Delivery of the shoulders with gentle traction
• Delivery of the body follows

Reprinted by permission from McGraw-Hill Education: Williams Obstetrics, 24th edition

Difficult Delivery of Fetal Head

• Is the fetal head floating?
  • Operative delivery of fetal head: forceps or vacuum
  • Internal podalic version
• Is the fetal head impacted in pelvis?
  • Use of a vaginal hand to de-station fetal head out of the pelvis and elevate toward the hysterotomy

• Fetal breech presenting part is grasped and brought to the hysterotomy
• Fetus delivered to level of the sacrum
• Rotate to sacrum anterior
• Wrap fetal body in moist blue towel and deliver to level of scapulae
• Rotate fetus side to side sweeping fetal arms over chest
• Mauriceau-Smellie-Veit maneuver: Operator index and middle fingers used to place gentle downward traction on fetal maxilla to flex fetal head; assistant may apply fundal pressure to assist

Delivery of Fetus

• Umbilical cord doubly clamped and cut: Delayed cord clamping should be considered
• Infant handed off the field to appropriate team (NICU/Peds/RN/OB) for assessment and resuscitation if needed
• Obtain cord blood and gas (if indicated): Can also be drawn from clamped segment of cord following delivery of placenta

Delivery of Placenta

• Spontaneous (gentle traction) or manual extraction of placenta
• Spontaneous preferred as it decreases risk of blood loss and endomyometritis
• Uterine cavity explored with a hand covered in a sponge gauze to remove any remaining placental tissue or membranes
• Intraveneous oxytocin administered to reduce uterine bleeding
• Additional uterotonics as needed
• Uterine massage to facilitate uterine contraction/involution

 

• Extra-abdominal (exteriorized) versus intra-abdominal uterine incision closure
  • Intra-abdominal closure associated with less nausea¹
  • No difference in surgical time or infection risk^2,3
  • No overall clinically significant difference although may be faster return of bowel function with in situ repair
• Evaluate for possible hysterotomy extensions – repair as necessary
• Single versus double layer closure
  • Many suggest double layer closure for women who desire future pregnancies
  • No randomized controlled trial to support¹
  • Either is acceptable
• Locked versus running suture closure -0- delayed absorbable suture
• Ensure hemostasis
• Abdominal irrigation versus no irrigation
  • Routinely performed in many centers, no proven benefit; may increase intraoperative nausea and vomiting and postoperative nausea¹

¹American College of Obstetricians and Gynecologists. Fetal macrosomia. ACOG Practice Bulletin 22. Washington, DC: ACOG; 2000.
²Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004737. DOI: 10.1002/14651858.CD004737.pub2.
³Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118:29-38.

• Peritoneal layer closure versus no closure
  • No significant benefit from closure noted
• Fascial closure
  • Continuous or interrupted suture closure
  • Delayed absorbable monofilament or braided suture
• Subcutaneous space closure
  • No clear evidence regarding irrigation versus no irrigation
  • Recommended if depth greater than 2 cm
  • Routine use of subcutaneous drain placement not recommended
• Skin Closure
  • Subcuticular suture versus staples
    • Composite wound morbidity less with suture