Volume 67, Number 8

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright * 2012
by Lippincott Williams & Wilkins

CME REVIEW ARTICLE

CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 Creditsi can be earned in 2012. Instructions for how CME credits can be earned appear on
the last page of the Table of Contents.

22

Cesarean Delivery Technique: Evidence

or Tradition? A Review of the
Evidence-Based Cesarean Delivery
Betsy Encarnacion, MD* and Marya G. Zlatnik, MD, MMS
*Resident Physician, and Associate Clinical Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology,
and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
Cesarean delivery is the most common surgical procedure performed in the United States, yet the
techniques used during this procedure often vary significantly among providers. The purpose of this
review was to evaluate and outline current evidence behind the cesarean delivery technique. A search
of the PubMed database was conducted using the terms cesarean section and cesarean delivery and
the technique of interest, for example, cesarean section prophylactic antibiotics. Few aspects of the
cesarean delivery were found to have high-quality consistent evidence to support use of a particular
technique. Because many aspects of the procedure are based on limited or no data, more studies on
specific cesarean delivery techniques are clearly needed. Providers should be aware of which components of the cesarean delivery are evidence-based versus not when performing this procedure.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: At the completion of this article, the reader should be able to assess evidenced-based perioperative and intraoperative techniques, evaluate which portions of the cesarean delivery are based on little to no evidence and data, and manage obese patients at the time of cesarean delivery.

Cesarean delivery is the most common surgical procedure performed in the United States.1 In 2009, 1.3
million births, or 32.3% of the births in the United
States, were by cesarean.2 One of the oldest surgical
procedures performed today, the cesarean delivery
has its origins traced back to ancient times and has
evolved over its longstanding history into the surgery
we currently perform.3 The cesarean deliverys long
history gives room for variation in technique and differences in the procedure among providers. Evidencebased medicine is widely relied on across all medical
disciplines and surgical subspecialties to ensure qualThe authors did not receive funding for this study.
No conflicts of interest to disclose.
The authors, faculty, and staff in a position to control the content
of this CME activity and their spouses/life partners (if any) have
disclosed that they have no financial relationships with, or financial
interest in, any commercial organizations pertaining to this educational activity.
Correspondence requests to: Betsy Encarnacion, MD, 505
Parnassus Ave, Box 0132 San Francisco, CA 94143-0132. E-mail:
encarnacionb@obgyn.ucsf.edu.

ity and safety in patient care. Given how common the

cesarean delivery is today, and the cornerstone it holds
in modern-day obstetrics, and the techniques used
during a cesarean delivery deserve to be reviewed to
minimize morbidity and ensure best patient care and
outcome.
The purpose of this article was to review the evidence behind the techniques of a cesarean delivery.
Previous reviews have examined the evidence behind
key steps of the cesarean delivery.4Y6 This review adds
to previous work by including more recent data and
currently debated issues. In addition, given the widespread prevalence of obesity in the United States,
where pertinent, we will review the appropriate management of the obese patient at the time of cesarean
delivery.
SKIN PREPARATION
Postpartum infectious morbidity, including endometritis and wound infection, is higher after cesarean

www.obgynsurvey.com | 483

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Obstetrical and Gynecological Survey

delivery compared to vaginal delivery.7,8 Skin flora is

a major source of pathogens that can cause surgicalsite infection (SSI), and skin preparation has been
widely recommended and accepted for preoperative
skin antisepsis to decrease postoperative infections.9
No single mode of skin preparation has been lauded
as the optimal preparation, generally or specifically at
the time of cesarean delivery. Povidone-iodine paint
has been traditionally used at the time of surgery. A
recent retrospective cohort study comparing the traditional iodine paint technique to a protocol using a
3-minute iodine scrub in addition to the standard paint
technique demonstrated that a scrub and paint preparation was associated with a decrease in the rate of
postcesarean delivery infectious complications, such
as endometritis, sepsis, cellulitis, peritonitis, and salpingitis, compared to the paint technique alone.10 A
major limitation of this study, however, is that not
all patients received cefazolin prophylaxis preoperatively, a current standard practice described below.
More patients in the Scrub and Paint group in the
study, in fact, received antimicrobial prophylaxis. Although this confounding variable was controlled for,
further studies are needed in which patients routinely
receive antibiotic prophylaxis before widely implementing this protocol.
Although iodine has been traditionally accepted as a
mode of preoperative skin preparation, increasing evidence is emerging in support of the use of chlorhexidine. A recent randomized trial compared preoperative
surgical site cleansing with chlorhexidine-alcohol
to povidone-iodine.11 In this study, Darouiche et al
enrolled almost 900 patients undergoing cleancontaminated surgeries, spanning colorectal, small
intestinal, gastroesophageal, biliary, thoracic, gynecologic, or urologic operations, with the primary end
point being the occurrence of any SSI within 30 days
after surgery. The overall rate of SSIs, including both
deep and superficial infections, was significantly
lower in the chlorhexidine-alcohol group than in the
povidone-iodine group. This evidence suggests that
in clean-contaminated cases, chlorhexidine may be
better than traditional iodine paint. This study, however, did not specifically look at these outcomes at
the time of the cesarean delivery, which can carry the
infection risk of a contaminated wound when frank
chorioamnionitis is present.
Use of chlorhexidine gluconate (CHG) no-rinse
cloths before the patient is moved to the operating
room, in addition to the operative preparation, has also
been studied and associated with a reduction in the
overall SSI rate.12 The outcomes, however, were analyzed as a bundle of care, where multiple external

factors such as staff and nursing education and the

elimination of flash sterilization were instituted at
the same time. This limits the interpretation of the
effect of no-rinse cloths versus the rest of the bundle
on overall SSI risk reduction.
Cleansing of the vagina with an antiseptic solution
immediately before cesarean delivery is yet another
intervention that has been evaluated. In a recent Cochrane review of 4 randomized control trials including
a total of 1198 women, preoperative vaginal cleansing with povidone-iodine was found to be associated
with a reduced risk of endometritis.13 This risk reduction was particularly strong among women with
ruptured membranes. Interestingly, vaginal cleansing
did not reduce the number of febrile days or wound
complications after cesarean delivery. Theoretical concerns exist about fetal hypothyroidism after exposure to iodine antisepsis; these data, however, did not
identify adverse neonatal effects but did not specifically address this issue.
HAIR CLIPPING
Management of hair at the surgical site has been
evaluated in many studies, as it was long believed that
hair removal at the surgical site decreased contamination. A recent Cochrane review suggested that hair
removal at the time of surgery is not associated with
lower postoperative SSI rates14 and thus should be
done only if deemed necessary for better visualization during the procedure. Shaving the surgical site
with a razor is thought to cause microscopic breaks
in the skin and has been shown to be associated with
significantly more SSIs than clipping.15 Most studies
in the Cochrane review included only general, spinal,
and orthopedic surgeries, and some studies specifically excluded vaginal and gynecologic surgery; thus,
these results can only be extrapolated to cesarean deliveries. Patients should be encouraged not to shave
their suprapubic region close to their due dates.
URINARY CATHETER FOR
BLADDER DRAINAGE
A Foley catheter is commonly used to enable better
visualization of the operative field and limit injury by
decompressing the bladder, although the evidence for
its routine use is limited. A review of 2 randomized
controlled trials and 1 nonrandomized controlled trial
found that not using a Foley catheter routinely was
associated with a significantly lower incidence of urinary tract infections, lower rate of discomfort at first
voiding, less time until first voiding, and less time until

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Cesarean Delivery Technique

ambulation.16 Further, they found no significant differences in the rate of urinary retention, operating
time, and rate of intraoperative difficulties with or
without the routine use of a Foley. These studies included primary and repeat cesarean deliveries and did
not straight catheterize patients before the procedure.
Unfortunately, these trials were not powered to assess for a difference in intraoperative bladder injury.
Because of voiding concerns postoperatively in the
setting of regional or general anesthesia, however, a
Foley catheter will likely continue to be used routinely at the time of cesarean delivery.
MANAGEMENT OF THE PANNUS
The pannus of the obese woman often poses a significant challenge at the time of cesarean delivery. It
can limit the surgeons operative view and obstruct
access into the intra-abdominal cavity. Techniques,
such as taping-up of the abdominal pannus, are often used to retract the pannus; however, we were unable to find studies comparing various techniques for
the management of a large pannus.
PROPHYLACTIC ANTIBIOTICS
Use of perioperative antibiotics in the setting of cesarean delivery has been widely accepted as a means
of decreasing maternal infectious morbidity. A Cochrane review sited 86 randomized controlled trials
including more than 13,000 women in which there
was found to be a reduction in febrile morbidity, postoperative fever, endometritis, wound infection, and
urinary tract infection when prophylactic antibiotics
were used at a cesarean delivery, regardless of the
setting (elective or after labor).17 The American College of Obstetricians and Gynecologists (ACOG)
Committee on Obstetric Practice published an opinion piece in favor of antimicrobial prophylaxis administration for all cesarean deliveries, unless the
patient is already receiving appropriate antibiotics
(eg, in the setting of chorioamnionitis). In their statement, they advocate the use of antibiotic prophylaxis
administration within 60 minutes of the start of the
cesarean delivery.18 Mounting evidence in the last
several years has supported antibiotics at the time of
skin incision rather than at cord clamp. In a retrospective cohort study of more than 9000 women, antibiotic prophylaxis before skin incision was noted to
result in lower rates of postpartum endometritis and
wound infection without adverse effect on neonatal
infection rates or evaluation of the neonate.19
At our institution, a retrospective cohort study
found that introduction of a policy to administer an-

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485

tibiotics at the time of skin incision was associated

with a significant decrease in SSIs, from 6.4% to
2.5%, as well as a decrease in endometritis.20 These
findings illustrate the beneficial role hospital-wide
policy implementation regarding prophylactic antibiotics can have in patient care.
Which antibiotic to use has been the subject of ongoing debate; cefazolin, a first-generation cephalosporin, and ampicillin have been found to be equally
efficacious when used as single-dose regimens in the
reduction of infectious morbidity in women undergoing cesarean delivery.21,22 Although no consistent
benefit has been noted with either second- or thirdgeneration cephalosporins, there is a growing body of
evidence suggesting that use of broad-spectrum antibiotic, rather than use of a single narrow-spectrum
drug, may be beneficial.23 A Cochrane review of 15
clinical trials, meta-analyses, and observational studies as well as 9 publications of recommendations or
meta-analyses supporting current standards found that
an extended-spectrum regimen, including cefazolin
plus azithromycin, gentamycin, or metronidazole, is
effective in reducing maternal infection after cesarean delivery, decreasing hospital stay, and is costeffective.24 At our institution, we have adopted the
use of an extended-spectrum regimen for groups at
high risk for SSI, such as diabetic and/or obese patients, prolonged rupture of membranes, chorioamnionitis, and abbreviated scrub or preparation in emergent
cases. Further research and, ultimately, guidelines as
to which patients most benefit from this practice are
needed.
THROMBOEMBOLISM PROPHYLAXIS
The incidence of venous thromboembolism (VTE)
during pregnancy in women without predisposing
risk factors has been estimated to be 13:10,000.25
Although it is well known that surgery increases the
risk of venous thromboembolism in the general
population, the specific effect of a cesarean delivery
has not been defined, and recommendations for prophylaxis have been extrapolated from gynecologic
surgery literature. ACOG recommends use of sequential compression devices (SCDs) in low-risk women,
placed preoperatively and removed once women are
fully ambulatory.26 A retrospective cohort of 1067
cesarean deliveries at a single institution identified 5
episodes (0.47%) of symptomatic postoperative pulmonary embolism, all of which occurred in women with
additional predisposing risk factors, such as obesity,
severe preeclampsia, twin pregnancy, reoperation, and
immobilization.27 Women with additional risk factors

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486

Obstetrical and Gynecological Survey

for thromboembolism, including obesity, smoking, inherited or acquired thrombophilia, malignancy, heart
failure, immobility, history of thromboembolism, and
age greater than 35 years, are thus recommended to
receive mechanical and pharmacologic prophylaxis.
Identifying high-risk women who would benefit
from pharmacologic and mechanical prophylaxis has
been the issue of ongoing research. A recent prospective cohort study created a model to identify patients
who would benefit from additional thromboprophylaxis, based on major risk factors such as history of
VTE, and minor risk factors such as weight, parity,
and immobility (Table 1).28 This model was found to
effectively identify women who needed prophylaxis
while avoiding unnecessary pharmacological prophylaxis in low-risk women.
FETAL HEART RATE MONITORING
No clearly defined guidelines exist as to how long
the fetus should be monitored before a cesarean delivery. Obviously, fetal heart rate monitoring before
a cesarean delivery depends on the clinical scenario,
for example, urgent versus planned cesarean.
TABLE 1
Risk Stratification for VTE Prophylaxis After Cesarean Delivery
Risk Group

Recommended Prophylaxis

Very high (at least one)

Previous venous or
arterial thrombotic event

Antiphospholipid
syndrome
Chronic anticoagulation/
antiplatelet treatment
Antithrombin deficiency
High
Symptomatic
thrombophilia
Moderate (at least one)

Immobility
Age 938 y
Weight 980 kg
Parity 92
Varicose veins
Low
All other conditions

Sequential compression devices +

Type and duration of antithrombotic
treatment to be determined
individually after visit with a
subspecialist (eg, perinatologist,
hematologist)

Sequential compression devices +

LMWH prophylactic dosing
(40 mg subcutaneously daily)
for 96 wk after delivery
Sequential compression devices +
LMWH prophylactic dosing
(40 mg subcutaneously daily)
for 9 7 days after delivery

Sequential compression device

No pharmacologic prophylaxis

LMWH indicates low molecular weight heparin.

From Cavazza et al.28

ABDOMINAL INCISION
The type of abdominal skin incision is an important
decision in any case of abdominopelvic surgery. The
surgeon often considers multiple factors including
anticipated operating time, blood loss, and future tensile strength of the wound. Low-transverse, or Pfannenstiel, skin incisions and low vertical skin incisions
have been shown to have the same wound dehiscence
rate, but low-transverse skin incisions have a lower
rate of incisional hernia.29,30 One study published in
2012 found no difference in wound complication
rates based on the type of skin incision.31 In a large
Maternal-Fetal Medicine Units Network cohort study, a
vertical skin incision in an emergency setting has been
associated with a faster incision to delivery time (in
both primary and repeat cesarean deliveries) but a
longer median total operating time.32 Despite the
shorter incision to delivery time, there was no improvement in neonatal outcome. Vertical skin incisions in
the setting of primary emergent cesarean deliveries
have also been associated with a higher likelihood of
endometritis. In the obese population, a retrospective
cohort study found that in women with a body mass
index (BMI) greater than 35 kg/m2, an unplanned cesarean delivery with a vertical skin incision was associated with a greater overall wound complication
risk.33 Vertical skin incision and higher BMI have
also been associated with a higher wound separation
rate. For all of these reasons, there seems to be a
limited role for a vertical skin incision.
ABDOMINAL ENTRY
Methods of abdominal entry have been examined
in 2 Cochrane reviews. Joel-Cohen methods, which
include blunt extension of subcutaneous tissues, fascia, and separation of the rectus muscles, have been
associated with less operating time, less blood loss,
and lower analgesia requirement when compared to
sharp dissection methods.34,35 A limitation of these
reviews, however, is that they do not tease apart each
particular technical step but rather group together
studies that identified use of Joel-Cohen or
Pfannenstiel techniques. We were unable to identify randomized trials that specifically compare sharp
dissection versus blunt dissection of the subcutaneous
tissues during cesarean delivery and studies that identify use of a scalpel or electrocautery as preferable.
Dissection of the rectus muscles from the rectus
sheath is typically performed at the superior and inferior ends of the fascial incision to ensure better
visualization by allowing separation of the rectus

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Cesarean Delivery Technique

muscles. A randomized controlled trial of 120 women

found that this process at the inferior rectus sheath
may be unnecessary.36 The group that did not have
inferior rectus muscle dissection from the rectus sheath
had a significant reduction in postoperative pain and
a smaller drop in hemoglobin, although no difference
in estimated blood loss. Data in this area, however, remain too limited to draw conclusions about practice.
BLADDER FLAP
The need for a bladder flap is an ongoing area of
debate. When the visceral peritoneum is incised with
the scalpel at the time of hysterotomy and a bladder
flap created, the bladder is pushed away from the surgical field, potentially preventing bladder injury during the hysterotomy repair. In a randomized controlled
trial of 102 women, in which 1 group received a bladder flap at the time of cesarean delivery while the
other did not, omission of the bladder flap was associated with decreased operating time and decreased
incision-to-delivery interval, as well as reduced blood
loss, and need for analgesics.37 Exclusion criteria for
this study included prior surgery on the uterus, thus
only primary cesarean deliveries were included. A recent randomized controlled trial of 258 women undergoing primary or repeat cesarean delivery also
evaluated creation or omission of a bladder flap.38
This study found a shorter median skin incision-todelivery interval (difference of 1 minute) with omission of the bladder flap but no difference in total
operating time. No bladder injuries occurred in either
group; however, the authors note that the study was not
powered to specifically assess the effect of bladder
flap omission on bladder injury. Additional research
is needed to assess if the shorter incision-to-delivery
time with omission of a bladder flap is clinically relevant and if there is an effect on bladder injury.
UTERINE INCISION
A fresh knife has been traditionally used for the
hysterotomy; however, we were unable to identify specific studies with evidence for or against the need for
a fresh scalpel blade at the time of uterine incision.
Entry into the uterus is a critical step of the cesarean delivery. During this time, the fetus is exposed to
potential harm if the scalpel blade is passed too vigorously through the myometrium. Generally, blunt
entry through the deepest layer of myometrium is recommended to reduce fetal and surgical trauma. Allis
clamps can be used to elevate the myometrium to
avoid sharp injury to the fetus, with ultimate blunt

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487

entry into the uterine cavity with a single digit once

the myometrium has been sufficiently thinned and exposed with the scalpel. Blunt or sharp extension of the
uterine incision follows. In low-transverse hysterotomies, blunt extension has been shown to be safer
and easier than sharp expansion and has been associated with a reduction in mean blood loss at the time
of the procedure compared to sharp dissection.39,40
In contrast, sharp extension of the hysterotomy has
been associated with a greater amount of intraoperative blood loss, a greater drop in hematocrit level, a
greater incidence of postpartum hemorrhage, and a
greater need for subsequent transfusion.41 In addition, in a randomized trial of 811 women randomized
to blunt transverse or cephalad-to-caudad extension
of the hysterotomy, cephalad-to-caudad extension was
found to be associated with less risk of unintended
extension and less estimated blood loss.42 As a result,
at our institution, we have devised the mnemonic
BABE to aid providers in remembering these
simple steps to minimize fetal injury and intraoperative blood loss (Table 2).
CORD CLAMPING
Delayed versus immediate cord clamping at the time
of delivery is an issue of debate. Emerging evidence
suggests that delayed cord clamping in term deliveries is associated with increased iron stores and hemoglobin without increasing the risk of postpartum
hemorrhage.43,44 Delayed cord clamping has also been
associated with an increased risk of jaundice requiring phototherapy and polycythemia, the significance
of which, however, is unclear.
Studies specifically looking at fetal outcomes of
delayed cord clamping at the time of cesarean delivery are limited. Most studies of delayed versus early
cord clamping included a similar number of infants
delivered by cesarean delivery and those by vaginal
delivery, but the outcomes for delayed cord clamping at the time of cesarean delivery have not been reported separately. A randomized trial of 24 women
TABLE 2
Mnemonic for to Decrease Injury and Blood Loss at Uterine Incision
Dont Forget the BABE
B Y Breathe
A Y Allis clamps
B Y Blunt
E Y Extend

Pause before making the hysterotomy

Use Allis clamps, if needed, to help elevate
hysterotomy
Use a single digit to sweep over hysterotomy
bluntly between each scalpel pass
Extend hysterotomy bluntly, in cephalad to
caudad direction

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Obstetrical and Gynecological Survey

noted similarly elevated hematocrit levels with cord

milking at the time of cesarean delivery versus vaginal
delivery.45 Interestingly, 1 study noted that neonates
delivered vaginally had significantly longer delayed
cord clamp times (915 seconds) than those delivered
by cesarean delivery.46 Limited data about delayed
cord clamping at the time of cesarean are currently
available, and more research is needed in this area.

blood transfusion, which is the clinically significant

factor.50 Carbetocin, a long-acting oxytocin analog,
has been shown to have equivalent effects to those of
oxytocin on uterine tone and decreasing postoperative blood loss after cesarean delivery51; however, it is
not available in the United States at the time of this
publication.
EXTERIORIZATION OF UTERUS

PLACENTAL DELIVERY
There is variation in how the placenta is removed,
with some preferring manual removal and others simulating the maneuvers of a vaginal delivery by applying cord traction and performing direct uterine
massage. In several randomized controlled manual
removal of the placenta has been associated with
greater incidence of endometritis, greater blood loss, a
lower hematocrit level after delivery, and a longer
duration of hospital stay.47
The need to change gloves during a cesarean delivery is another point of variation. A randomized trial
of 228 women found that the incidence of postcesarean endometritis was not decreased by changing the
surgeons gloves after delivery of the infant and before placental extraction.48 We were unable to find evidence regarding the need for the surgeon to change
gloves after placental delivery and before completion
of the rest of the procedure.
PREVENTION OF HEMORRHAGE
At the time of cesarean delivery, a uterotonic agent
such as oxytocin is typically infused to reduce the risk
of postpartum hemorrhage. The exact regimen, and
whether a bolus or continuous infusion should be
given, remains without significant evidence. The use
of a bolus of intravenous oxytocin in addition to an
infusion has not been shown to change the need for
additional uterotonic drugs to prevent or treat postpartum hemorrhage.49
Women who have prolonged labor are at risk for increased bleeding and hemorrhage secondary to uterine
atony. The need to give these women higher additional doses of oxytocin was studied in a randomized
controlled trial of 2 oxytocin regimens in laboring
women. Either oxytocin regimen of 10 U/500 mL or
80 U/500 mL of Lactated Ringers Solution was infused over 30 minutes after cord clamping. Higher
concentrations of oxytocin in the first 30 minutes
postpartum was associated with a reduction in the
need for additional uterotonic agents at cesarean delivery, but there were no differences in the need for

The uterus is often exteriorized to allow for greater

exposure and visualization at the time of hysterotomy
closure. There is insufficient evidence, however, to
support exteriorization of the uterus for this purpose.
A Cochrane review identified 6 studies that compared
extra-abdominal versus intra-abdominal uterine repair. Extra-abdominal closure of the hysterotomy was
associated with lower febrile morbidity, but longer
hospital stay.52 A meta-analysis subsequently found
no differences in complication rates between extraabdominal and intra-abdominal hysterotomy repair at
the time of cesarean delivery.53 Yet another review
of more than 1000 cesarean deliveries, in which either in situ or extra-abdominal hysterotomy repair
was performed, found no clinically significant difference between groups with respect to mean differences in hematocrit levels, intraoperative blood loss,
perioperative nausea, tachycardia, hypotension, and
postoperative analgesic doses.54 The mean operative
time, time to the first recognized bowel movement,
SSI rate, and length of hospital stay, however, were
significantly lower in the in situ repair group. This
conflicting evidence suggests that more research is
needed to conclude which modality of hysterotomy
repair is preferable.
CERVIX OPENING
The cervix is often opened with a ring forceps
or clamp, particularly in unlabored patients, with the
belief that this maneuver will allow uterine debris
and clots to drain from the uterus thereby preventing
retained clots and potentially febrile morbidity. A Cochrane review of 3 trials found no difference in febrile morbidity or in wound infection with manual
cervical opening versus not.55 Furthermore, we were
only able to find limited evidence that evaluated blood
loss risk with cervical opening. One randomized
study evaluated the estimated blood loss with cervical opening versus nonopening and found a nonsignificant mean decrease in blood loss of 50 mL with
opening compared to nonopening.56 The clinical significance of a difference of 50 mL of blood loss at

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Cesarean Delivery Technique

the time of a cesarean delivery, however, is unclear.

No studies that specifically evaluated postpartum hemorrhage risk with or without mechanical cervical dilation at the time of cesarean delivery were identified.
UTERINE CLOSURE
Many women who have a cesarean delivery wish
to attempt a trial of labor after cesarean (TOLAC) in
a future pregnancy, of which the most serious complication is that of uterine rupture. This concern often
guides the surgeons decision to perform a single- or
a double-layer closure of the hysterotomy at the index cesarean delivery. The short-term benefits of
single-layer closure oppose the long-term outcomes
seen with double-layer closure, therefore, a provider
must understand the patients likelihood of undergoing a trial of labor in a future pregnancy when deciding how to approach this portion of the cesarean
delivery. In a Cochrane review of 10 studies, singlelayer closure was associated with a statistically significant reduction in mean blood loss of approximately
70 mL, decreased duration of the procedure by
7 minutes, and less postoperative pain compared with
the double-layer closure.39 When single-layer uterine
closure is performed, single-layer continuous suture
is preferred over interrupted suture for hysterotomy
closure because continuous single-layer closure was
found to be associated with faster operating time,
smaller drop in hemoglobin level, and no difference
in febrile morbidity, length of hospital stay, or readmission.57 In considering the short-term outcomes of
the procedure in isolation, a single-layer closure seems
beneficial.
Long-term outcomes, such as the risk of uterine rupture, however, support double-layer closure. In a
retrospective case-control study of uterine rupture,
authors found that prior single-layer closure of the
uterus was associated with an increased risk of
uterine rupture when compared with double-layer
closure.58 Specifically, locked single-layer closures
have been retrospectively associated with a higher
uterine rupture risk in women attempting TOLAC
when compared to women with a double-layer closure.59 Therefore, considering long-term outcomes,
double-layer closure should be considered in women
who may wish to have a trial of labor in the future.
ADHESION BARRIERS
With the rise in cesarean deliveries over the last several decades, attention has been turned to the use of
adhesion barriers to potentially minimize adhesions

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489

and prevent difficult surgery and injury at a future cesarean delivery or abdominal surgery. Evidence from
the gynecology literature suggests that at the time of
a laparotomy, a synthetic adhesion barrier, such as
Seprafilm or Interceed, may be beneficial in reducing
adhesion formation.60,61 A retrospective cohort study
evaluated the presence of adhesions at a repeat cesarean delivery and found that adhesion barriers were
associated with a higher likelihood of having no adhesions at repeat cesarean compared to the noYadhesion
barrier group.62 Whereas studies to assess the efficacy
of adhesion barriers are ongoing, the cost-effectiveness
of adhesion barriers remains to be studied.63
PERITONEAL CLOSURE
Peritoneal closure is another area of controversy.
Nonclosure of the peritoneum has been associated
with improved short-term outcomes, including shorter
operating times, decreased postoperative fever, and
decreased postoperative hospitalization,64 but limited
long-term outcome data exist. A prospective cohort
found that closure of the peritoneum at an index cesarean delivery was associated with fewer dense and
filmy adhesions at the time of repeat cesarean delivery; however, there were significant ethnic differences
between the groups.65 In contrast, a randomized controlled trial by Kapustian et al66 suggested that peritoneal closure at a first cesarean does not contribute
to decreased adhesion formation or decreased operating time at the time of a repeat cesarean delivery. As
data remain limited and conflicting, more research is
needed in this area.

IRRIGATION/CLEANING OF
THE ABDOMEN/PELVIS
Before closing the abdomen, the abdominopelvic
gutters are often cleared of clots with a suction tip or
laparotomy sponge with the thought that leaving clots
in the abdomen causes peritoneal irritation and can
increase postoperative pain. This step can often be
uncomfortable for the patient and may stimulate nausea and vomiting. We were unable to identify studies
that evaluated this practice.
Intra-abdominal irrigation during cesarean delivery,
performed with the same purpose of cleaning clots
and blood from the abdominopelvic cavity, has been
evaluated in a randomized trial of 196 women but has
not been proven to reduce estimated blood loss, operating time, hospital stay, or infection, and thus is
not advocated.67

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Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Abdominal entry

Abdominal incision

Fetal heart rate monitoring

VTE prophylaxis

Prophylactic antibioticsVdrug

Pannus retraction
Prophylactic antibioticsVtiming

Foley

Hair clipping

Vaginal preparation

Skin preparation

Technique

TABLE 3
Summary of Techniques
Evidence-Based Technique

No evidence for best practice; dependent

on clinical scenario
Low-transverse incision associated with
lower rate of incisional hernia; vertical
skin incision associated with higher risk
of endometritis
Blunt techniques associated with shorter
operative time, less blood loss, and less
anesthesia requirement

Povidone-iodine; chlorhexidine is associated

with a lower rate of SSIs
Vaginal iodine scrub in addition to routine
abdominal preparation associated with
a lower risk of endometritis
Hair clipping not associated with lower rates
of postoperative SSIs
Routine use of a Foley not associated with
significant differences in the rate of urinary
retention, operating time, and rate of
intraoperative difficulties
No evidence for best practice identified
Use at skin incision vs cord clamp
associated with lower rate of
endometritis and wound infection
First-generation cephalosporin or
ampicillin associated with decreased
infectious morbidity
Women with risk factors should receive
mechanical and pharmacologic
prophylaxis

Limitations

No direct comparison of sharp vs blunt

techniques of each particular step

Recommendations for prophylaxis are

extrapolated from gynecologic
surgery literature

Limited data on who would benefit from

extended-spectrum regimen

V
V

Studies often excluded vaginal and

gynecologic surgery
Trials not powered to assess for a
difference in intraoperative
bladder injury

Chlorhexidine data are not specific to

cesarean delivery
No data about neonatal iodine exposure

Interpretation

Use blunt techniques when possible

Opt for low-transverse skin incision

All women should have SCDs;

additional prophylactic
pharmacologic prophylaxis
for patients with 1+ risk factor
Potential area for future study

Use of cefazolin or ampicillin

preoperatively

Area of needed research

Use prophylactic antibiotics at skin
incision

Routine Foley may continue to be

used because of voiding concerns
postoperatively

Clip rather than shave, if needed

Consider in patients with ruptured

membranes

Use of chlorhexidine preferred

490
Obstetrical and Gynecological Survey

Skin closure

Irrigation/cleaning of the
abdomen/pelvis
Rectus muscle closure
Fascial closure
Management of the subcutaneous
space

Adhesion barriers
Peritoneal closure

Uterine closure

Uterotonics
Exteriorization of the uterus
Cervix opening

Placental delivery

No evidence identified
Use at least 1-0 absorbable braided suture
Closure of subcutaneous space 92 cm
associated with decreased risk of wound
hematoma or seroma; irrigation not
associated with decreased wound infections
Subcuticular closure associated with lower
rate of wound separation

Blunt extension of hysterotomy,

cephalad-to-caudad, associated with
decreased blood loss
Limited data regarding delayed cord clamping
at the time of cesarean delivery
Manual removal associated with greater blood loss,
longer hospital stay, and risk of endometritis
No evidence for uterotonic regimen identified
Conflicting evidence
No difference in febrile morbidity with opening
compared with not opening
Single-layer closure associated with decreased
blood loss and shorter procedure;
double-layer closure associated with lower
risk of uterine rupture
Evidence supporting decreased adhesion formation
Conflicting evidence supporting decreased
adhesions at repeat cesarean
No evidence identified

Uterine incision

Cord clamping

Omission of bladder flap associated with 1-min

shorter skin-to-delivery time

Evidence-Based Technique

Bladder flap

Technique

No data regarding wound closure

techniques in the obese patient

V
Extrapolated from general surgery
No data regarding technique and suture
type

No evidence regarding cost-effectiveness

Limited long-term data

V
V
Limited evidence; studies did not
assess postpartum hemorrhage risk
V

Study not powered to assess effect

on bladder injury; unclear significance
of 1-min difference
V

Limitations

Close incision with subcuticular

closure when possible

No need to clean gutters or irrigate

pelvis
Additional research needed
Additional research needed
Close subcutaneous space if 92 cm

More research is needed

Additional research needed

Double-layer closure if possible

TOLAC; if single layer performed,
opt for continuous nonlocking

Opt for direct uterine massage and

cord traction
More research is needed
More research is needed
More research is needed

Additional research needed

Use cephalad-to-caudad blunt

extension when possible

Additional research needed

Interpretation

Cesarean Delivery Technique

& CME Review Article

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491

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Obstetrical and Gynecological Survey

RECTUS MUSCLE CLOSURE

The rectus muscles are occasionally reapproximated at the time of cesarean delivery to decrease the
risk of abdominal wall diathesis. Our search did not
identify studies that evaluate the efficacy of rectus
muscle closure at the time of cesarean delivery in
preventing abdominal wall diathesis or its effects on
postoperative pain, healing, or adhesion formation.
CLOSURE OF FASCIA
Closure of the fascia is often deemed to be one of
the most important steps in any abdominal surgery.
Improperly closed fascia can be a risk factor for fascial dehiscence and wound complications. Although
this particular aspect of abdominal surgery is highly
important, techniques to close fascia vary among providers. Although we were unable to identify data regarding fascial closure specifically at the time of
cesarean delivery, the practice in general surgery in
the setting of a transverse abdominal incision is generally to close the fascia continuously with slowly absorbable braided suture with a strength of 0 or 1.68
Studies we identified in the general surgery literature
that have evaluated fascial closure techniques have
been performed in the setting of a vertical incision,
generally not applicable to our cesarean delivery cohort.
Points of variation in the fascial closure of a lowtransverse incision include use of a single suture to reapproximate the entire incision versus using 2 sutures
that meet in the midline. In addition, when using 2
fascial sutures that meet in the midline, some providers prefer to tie untied strands together, whereas
others prefer to tie down 1 side with a knot and then
tie the loops from the first suture to the second suture.
We did not identify clinical data in favor of either
technique, and thus, this remains an area for potential
investigation.
MANAGEMENT OF THE
SUBCUTANEOUS SPACE
Management of the subcutaneous space has been
an area of much research, particularly in overweight
or obese women. In a randomized trial of 280 women,
a subcutaneous drain was demonstrated to not be effective in preventing wound complications in obese
women after cesarean delivery.69 In contrast, closure
of the subcutaneous space with suture in women with
a subcutaneous space thickness of more than 2 cm
has been shown to have a decreased risk of hematoma
or seroma, as well as wound infection and separation,
compared with nonclosure.70,71 No studies regarding

the optimal needle and suture type for closure of the

subcutaneous space, use of a running versus interrupted stitch, and the effectiveness of double-layer
closure in patients with subcutaneous depths significantly more than 2 cm were identified in our search
and remain potential areas of future research.
The subcutaneous space is also often irrigated with
saline before closure in the hopes of removing bacteria and debris that could be the source of a future
wound complication. In a randomized trial of 520
women, wound irrigation before wound closure was
not shown to reduce wound infection rates after cesarean delivery.72 Additional studies are needed to
confirm these findings.
SKIN: STAPLES VERSUS SUBCUTICULAR
Evidence for skin closure supports the use of subcuticular suture at the time of cesarean delivery. In a
randomized trial, staples and subcuticular suture were
found to have an equivalent cosmetic appearance73;
however, subcuticular closure has been found to have
a lower rate of wound separation and wound complications when compared to staples.74,75 No studies
that specifically evaluated wound closure techniques
in the obese patient were identified.
CONCLUSIONS
In summary, few steps in a cesarean delivery are
based on level I data, whereas many steps have limited
or no evidence. Techniques that are supported by medical evidence include the use of a first- or secondgeneration cephalosporin for preincision preoperative
antibiotic prophylaxis, entering the abdomen with a
Joel-Cohen technique, expanding the uterine incision
bluntly, delivering the placenta spontaneously, closing the subcutaneous space in obese women, and suturing the skin incision (Table 3). Of those techniques
for which there is evidence, it is our duty to our patients to critically evaluate the literature supporting
the practice of such techniques and use techniques
forwhich there is evidence during surgery. Areas with
limited data remain open for future research.
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