Cesarean birth: Surgical technique

Author:
Vincenzo Berghella, MD
Section Editor:
William Grobman, MD
Deputy Editor:
Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jun 2022. | This topic last updated: Jun 17, 2022.

INTRODUCTION As with most surgical procedures, there is no

standard technique for cesarean birth. The following discussion will review each
step in the procedure and provide evidence-based recommendations for
surgical technique, when these data are available. In many cases, when
comparisons showed statistical significance, the absolute differences are
sufficiently small that differences in outcome among surgical techniques are not
clinically important; in these settings, time and cost savings assume greater
importance [1].

Other aspects of cesarean birth are reviewed separately:

●(See
"Cesarean birth: Preoperative planning and patient
preparation".)
●(See "Anesthesia for cesarean delivery".)
●(See "Cesarean birth: Postoperative issues".)
●(See "Repeat cesarean birth".)
●(See "Cesarean birth on maternal request".)
The Enhanced Recovery After Surgery (ERAS) Society has published
guidelines for perioperative care of patients undergoing cesarean birth, the
ERAS Cesarean Delivery Guidelines, which cover the time from decision to
operate (starting with the 30 to 60 minutes before skin incision) to hospital
discharge [2-4]. The American College of Obstetricians and Gynecologists has
published a guideline for enhanced recovery after surgery [5]. Other
organizations and many hospitals have also created such guidelines/pathways
[6].

OPENING THE ABDOMEN The advantages and disadvantages of

various incisions and the procedure for opening the abdomen from skin to
peritoneum are generally the same as for any open abdominal surgery.
(See "Incisions for open abdominal surgery".)
Skin incision
Choice of incision — For most patients, we prefer a transverse skin incision
since it is associated with a better cosmetic appearance and possibly less
postoperative pain and hernia formation than the vertical midline skin incision
[7-9]. Although we rarely perform a vertical midline incision, we often select this
approach when:
 ●A transverse incision may not provide adequate exposure
●The patient has a bleeding diathesis and thus is at increased risk
of subcutaneous or subfascial hematoma formation
Incision-to-delivery time is important but generally not a reason to choose a
vertical incision because a vertical incision saves about one minute in primary
and two minutes in repeat cesarean births compared with a transverse incision
[10].
Transverse incisions — Two common transverse incisions for cesarean birth
are the Pfannenstiel type and the Joel-Cohen type incisions (also called Misgav
Ladach) (figure 1).
●The Pfannenstiel skin incision is slightly curved, 2 to 3 cm above
the symphysis pubis, with the midportion of the incision within the
clipped area of the pubic hair.
●The Joel-Cohen type incision is straight, 3 cm below the line that
joins the anterior superior iliac spines, and slightly more cephalad
than Pfannenstiel [11].
In meta-analyses of randomized trials of surgical incisions for cesarean birth,
the Joel-Cohen type incision had several statistically significant short-term
advantages compared with the Pfannenstiel incision, including lower rates of
fever, postoperative pain, and use of analgesia; less blood loss; and shorter
operating time (overall and incision-to-delivery) and hospital stay [12-14]. In two
trials (411 participants) comparing the incisions, the Joel-Cohen incision
resulted in a 65 percent reduction in postoperative febrile morbidity (relative risk
[RR] 0.35, 95% CI 0.14-0.87) and a 45 percent reduction in postoperative
analgesic requirements (RR 0.55, 95% CI 0.40-0.76), as well as shorter incision
to delivery time (mean difference [MD] -1.90 minutes, 95% CI -2.53 to -1.27 ),
shorter operating time (MD -11.40 minutes, 95% CI -16.55 to -6.25), lower
estimated blood loss (MD -58.00 mLs, 95% CI -108.51 to -7.49), and shorter
postoperative maternal hospital stay (MD -1.50 days, 95% CI -2.16 to -0.84)
[15]. However, many surgeons continue to prefer the Pfannenstiel incision, in
part because it is somewhat lower on the abdomen and therefore has a less
negative cosmetic appearance and because many of these differences,
although statically significant, are not clinically important.
In patients with severe obesity, a supraumbilical incision may be preferable to a
suprapubic incision, but this decision needs to be individualized based on the
patient's anatomy and fat distribution. (See "Cesarean birth: Overview of issues
for patients with obesity", section on 'Abdominal wall incision'.)
Vertical incision — Compared with transverse incisions, a vertical midline
incision generally causes less bleeding and superficial nerve injury, can be
easily extended cephalad if more space is required for access, and allows
slightly faster abdominal entry. In a prospective cohort study including over
3500 emergency cesarean births, the median incision to delivery interval was
faster for vertical than transverse skin incisions (three versus four minutes for
primary cesareans and three versus five minutes for repeat cesareans), but
neonatal outcomes were not improved, and some maternal and neonatal
outcomes were worse in the vertical incision group (eg, need for postpartum
maternal transfusion [8.5 versus 5.3 percent], neonatal intubation in the delivery
room [17 versus 13 percent]) [10]. The poorer outcomes were attributed to
unidentified confounders since the choice of skin incision is not independent of
the indication for cesarean birth.
In patients with severe obesity, a supraumbilical incision may be preferable to a
subumbilical incision, but this decision needs to be individualized based on the
patient's anatomy and fat distribution. (See "Cesarean birth: Overview of issues
for patients with obesity", section on 'Abdominal wall incision'.)
Scalpel or electrocautery? — The author prefers incising with a scalpel rather
than an electrocautery device, but there is no clear evidence of superiority in
short- or long-term outcomes between the two, and so the surgeon's preference
is reasonable. The body of evidence from randomized trials in general surgery
patients [16-18] and a small trial in patients undergoing repeat cesarean [19]
shows that neither scalpel nor electrosurgery holds a clinically significant benefit
over the other for skin incision; either approach or a mixture of the two
approaches is acceptable. (See "Incisions for open abdominal surgery", section
on 'Skin incision'.)
It is not necessary to change to a fresh scalpel blade after opening the
abdomen, given that the rate of wound infection appears to be similar with a
one-scalpel versus two-scalpel technique [20].
Subcutaneous tissue layer — There are no randomized trials comparing
techniques for incision and dissection of the subcutaneous tissues at cesarean
birth. We prefer blunt dissection (with fingers) over sharp dissection (with the
knife), as blunt dissection has been associated with shorter operative times,
less chance of injury to vessels, and less postoperative pain [21,22]. The tissue
is opened from medial to lateral.
Fascial layer — A small transverse incision is usually made medially with the
scalpel and then extended laterally with scissors. Alternatively, the fascial
incision can be extended bluntly by inserting the fingers of each hand under the
fascia and then pulling in a cephalad-caudad direction, which is part of the Joel-
Cohen/Misgav-Ladach technique [11,21] (see 'Alternative techniques' below). A
randomized trial of sharp versus blunt fascial incision using each patient as her
own control (sharp dissection for half the incision and blunt dissection for the
other half) found no difference in postoperative pain scores but was too small
(28 patients) to detect modest differences [23].
Rectus muscle layer — Rectus muscles can be separated bluntly in most
cases. Transection of the muscles (ie, Maylard technique) is avoided, if
possible, as leaving the muscles intact preserves muscle strength in the early
postoperative months; otherwise, there are no clear differences in outcome
between the two techniques [24-26].
Dissection of the rectus fascia from the rectus muscles appears to be
unnecessary, although commonly performed [21,22,27]. In one small
randomized trial, non-dissection resulted in higher postoperative hemoglobin
levels and less pain [28].
Opening the peritoneum — We favor using fingers to bluntly open the
peritoneum to minimize the risk of inadvertent injury to bowel, bladder, or other
organs that may be adherent to the underlying surface, as in the Joel-Cohen
type approach [21,22,27]. However, a sharp technique is also acceptable. In a
large randomized trial (CORONIS) that examined five elements of the cesarean
birth technique in intervention pairs, there was no significant difference between
blunt and sharp technique for the primary composite outcome of maternal
death, infectious morbidity, further operative procedures, or blood transfusion
>1 unit [29,30].
An extraperitoneal approach is another option. Most obstetricians are not
familiar with this technique since it was used primarily in the pre-antibiotic era to
decrease the risk of intraperitoneal infection. It requires a detailed knowledge of
the relationship between the fascial planes and the bladder and lower uterine
segment. Theoretically, avoiding exposure of the peritoneal cavity to blood,
amniotic fluid, vernix, and mechanical irritation can potentially reduce nausea
and vomiting, postoperative pain, voiding disturbances, and other side effects
and complications of cesarean birth. This hypothesis is supported by a small
randomized trial that compared the transperitoneal and extraperitoneal
techniques and found the latter resulted in less intraoperative nausea and
vomiting and less postoperative pain [31].

A Maylard incision or an extraperitoneal approach may be useful in patients with

dense adhesions between the lower uterine segment and the peritoneum but is
very rarely needed.

Avoiding visceral injury in patients with dense intraperitoneal

adhesions — If there are dense adhesions between the anterior abdominal
wall and the anterior surface of the uterus, we enter the peritoneum bluntly and
as close as possible to the upper abdomen to avoid these areas. Sharp
dissection also may be needed and should be performed cautiously by making
shallow incisions under direct vision. Other approaches are to start laterally or
use a paravesical or supravesical extraperitoneal approach to avoid dense
midline adhesions [32].
A surgeon experienced in complex abdominal surgery should assist if
meticulous dissection of dense adhesions involving important structures is
needed. Insertion of ureteral stents can be useful to facilitate intraoperative
identification (and avoidance) of the ureters, but is rarely indicated for cesarean
birth; there is no level 1 evidence of benefit in the setting of cesarean birth with
dense adhesions. (See "Urinary tract injury in gynecologic surgery:
Epidemiology and prevention", section on 'Prophylactic ureteral catheters
(stents)'.)
If pelvic adhesions require extensive dissection with risk of injury to the bowel,
urinary tract, or major blood vessels to expose the lower uterine segment, and
the patient desires tubal ligation, we avoid or minimize adhesiolysis and perform
the hysterotomy in the most appropriate accessible location. A case report in
which the entire length of the ventral aspect of the uterus and bladder was
densely adherent to the rectus sheath described extending a vertical incision in
the abdominal wall above the level of the adhesions and then entering the
uterine cavity through an incision across the fundus [33].
Ensuring adequate exposure — The full thickness abdominal wall incision
should be adequate to allow easy delivery of the fetus. While there are no trials
on this technical aspect of cesarean birth, a 15 cm incision (the size of a
standard Allis clamp) will likely allow atraumatic and expeditious delivery of the
term fetus [11] The surgeon and an assistant together can manually stretch
apart the opening at the angles of the incisions if needed, but additional sharp
dissection may be necessary.

INTRAABDOMINAL PROCEDURES
Bladder flap — We do not routinely create a bladder flap. In a meta-analysis of
four trials that randomly assigned patients to undergo or not undergo
development of a bladder flap at cesarean birth, omitting this procedure did not
increase short-term adverse outcomes (bladder injury, blood loss, duration of
hospitalization) and reduced the incision-to-delivery interval by 1.3 minutes [34].
The trials excluded very preterm and emergency deliveries. These data are
inadequate to definitively assess uncommon morbidities, such as bladder injury,
or the long-term consequences of not creating a bladder flap, such as long-term
bladder function.
A subsequent randomized trial found that urinary symptom scores at 6 to 8
weeks postpartum were similar whether or not a bladder flap was performed,
but patients who received a bladder flap had more bothersome urinary
symptoms [35].

Some obstetricians choose to selectively perform a bladder flap if a difficult

delivery is anticipated, such as when the fetal head is deep in the pelvis or
when the bladder is attached well above the lower uterine segment after a
previous cesarean birth. In these cases, creation of the bladder flap may help to
keep the bladder dome out of the surgical field if the uterine incision extends. In
some patients, such as those who are not in labor, it may not be possible to
make an incision in the lower uterine segment without first creating a bladder
flap.

The location of the bladder is best delineated by palpating the bladder catheter,
if present. The demarcation between the lower and upper uterine segments is
difficult to determine clinically, sonographically, or histologically. The location or
level of the demarcation also changes based on the clinical situation.

Hysterotomy
Choice of incision — The uterine incision is usually transverse but may be
vertical; no randomized trials have compared the two techniques. The principal
consideration is that the incision must be large enough to allow atraumatic
delivery of the fetus. Factors to consider include the position and size of the
fetus, location of the placenta, presence of leiomyomas, development of the
lower uterine segment, and future pregnancy plans. Small comparative studies
of transverse and vertical incisions have not reported a difference in incision to
delivery time or short-term maternal and infant outcomes between the two
techniques [36,37]. However, if the patient has a subsequent pregnancy, she
may be at higher risk of uterine rupture if she has a low vertical incision and
chooses to undergo a trial of labor.
Prior to making a hysterotomy incision, the surgeon should generally be aware
of the fetal lie and the placental location on the last ultrasound examination.
This information helps in avoiding laceration of the placenta and in delivery of
the fetus. If labor has been prolonged and the head is deep in the pelvis, the
lower uterine segment may be very thin and retracted superiorly. In these
cases, it is important to avoid making the incision too inferiorly as it may
transect the cervix or vagina. Accidental laparoelytrotomy (ie, delivery of the
fetus through a vaginal incision) can be avoided by remembering that the
uterovesical fold is usually at the upper margin of the lower segment; thus, the
uterine incision should be made just above, or at a maximum a centimeter
below, this anatomic landmark [38-40].
Transverse incision — For most cesarean births, we recommend making a
transverse incision along the lower uterine segment (ie, Monro Kerr or Kerr
incision). Compared with vertical incisions, advantages of the transverse
incision include less blood loss, less need for bladder dissection, easier
reapproximation, and a lower risk of rupture in subsequent pregnancies [11]. It
is the best incision for patients who are planning another pregnancy and may
attempt a trial of labor in that pregnancy. (See "Choosing the route of delivery
after cesarean birth", section on 'One prior low transverse uterine
incision' and "Choosing the route of delivery after cesarean birth", section on
'Prior low vertical uterine incision'.)

The major disadvantage of the transverse incision is that significant lateral

extension is not possible without risking laceration of major blood vessels. A "J"
or inverted "T" extension is often required if a larger incision is needed. This can
be problematic because the "J" extension goes into the lateral fundus and the
angles of the inverted "T" incision are poorly vascularized. Both the J and T
incisions potentially result in a weaker uterine scar, which is a concern if the
patient has a subsequent pregnancy.

Low vertical and classical incisions — There are two types of vertical
incisions: the low vertical (Kronig, DeLee, or Cornell) and the classical. The low
vertical is performed in the lower uterine segment and appears to be as strong
as the low transverse incision [41]. The major disadvantage of the low vertical
incision is the possibility of extension cephalad into the uterine fundus or
caudally into the bladder, cervix, or vagina. It is also difficult to determine
whether the low vertical incision is truly low, as the separation between lower
and upper uterine segments is not easily identifiable.
A classical incision is a vertical incision that extends into the upper uterine
segment/fundus. This incision is rarely performed at or near term because in
subsequent pregnancies it is associated with a higher frequency of uterine
dehiscence/rupture (4 to 9 percent) compared with low vertical or transverse
incisions (0.2 to 1.5 percent); it is also associated with more maternal morbidity
[42,43]. (See "Uterine rupture: After previous cesarean birth".)

Whether a vertical incision is confined to the lower, noncontractile portion of the

myometrium (low vertical) or extends into the upper contractile portion of the
myometrium (classical) is a subjective assessment; no objective method for
differentiating between the two types of uterine incisions is available. However,
if the incision extends to the level or near the level of the round ligament
insertion, it should definitively be considered classical.

The generally accepted indications for considering a vertical uterine incision

are:

●Poorly developed lower uterine segment when more than normal

intrauterine manipulation is anticipated (eg, extremely preterm
breech presentation, back down transverse lie).
●Lower uterine segment pathology that precludes a transverse
incision (eg, large leiomyoma, anterior placenta previa or accreta).
●Densely adherent bladder.
●Postmortem delivery.
 ●Delivery of a very large fetus (eg, anomalous, extreme
macrosomia) when there is high risk of extension of a transverse
incision into uterine vessels or a T or J extension may be required
to extract the fetus.
Procedure — Hysterotomy is begun by making a small incision with a scalpel.
Various techniques are used to minimize the risk of fetal injury while making this
incision. All involve elevating and carefully thinning the inner myometrial and
decidual layers to minimize bleeding, maximize exposure, and promote
separation of the uterine tissue from the fetal membranes or skin.

After the initial incision on the uterus has been made with the scalpel, and most
of the uterine wall has been cut, we prefer to enter the uterine cavity with the
index finger of the dominant hand of the surgeon, in a blunt fashion. This is
effective >90 percent of the time in our experience, reduces blood loss, and
avoids any risks of fetal injury with a sharp instrument. If this is not easily
accomplishable, the next steps may be helpful:

●Consider applying Allis clamps to the superior and inferior edges

of the myometrial incision and elevate them, as needed.
●Remove the suction tip and directly apply the end of the suction
tubing to the center of the myometrial incision to balloon out and
thin out this layer while providing easily identifiable, relatively
blood-free exposure. If possible, leave the membranes intact until
complete extension of the incision.
Expanding the incision — After the uterine cavity is entered, the hysterotomy
incision is extended using blunt expansion with the surgeon's fingers or
bandage scissors. We recommend blunt expansion because it is fast, has less
risk of inadvertent trauma to the fetus, and has maternal benefits. Specifically,
in a meta-analysis of randomized trials, cephalad-caudad blunt extension (eg,
pulling cephalocaudally with the index fingers to extend the uterine incision
transversely) reduced the risk of unintended incision extension (RR 0.62, 95%
CI 0.45–0.86) and uterine vessel injury (RR 0.55; 95% CI 0.41–0.73) [44].
Uterine stapler — We do not use the auto stapler. A meta-analysis of two small
randomized trials did not show any benefits over conventional sharp dissection
[45]. This technique should be reserved, if used at all, for rare indications (eg,
ex utero intrapartum treatment [EXIT] procedure).
Fetal extraction — The goal should be to extract the fetus expeditiously and
nontraumatically. Most studies, but not all [46,47], have reported a direct
association between a prolonged uterine incision-to-delivery time and lower
fetal blood gas pH values and Apgar scores, regardless of type of anesthesia
[48]. The mechanism is thought to be hysterotomy-induced increased uterine
tone, which can interfere with uteroplacental blood flow.
Extraction of the fetus at cesarean is usually uncomplicated. For fetuses in
cephalic presentation, the key points are placing the obstetrician's fingers
around the curvature of the head for leverage, lifting without overly flexing the
wrist, and not using the lower uterine segment as a fulcrum, which can lead to
extensions of the hysterotomy incision, if done improperly. The obstetrician
usually inserts the dominant hand through the hysterotomy incision and around
the top of the fetal head. Standing on a stool may be helpful. Using the fingers
and palm, the head is gently elevated and flexed to bring the occiput into the
open hysterotomy, and then guided through the incision, aided by modest
transabdominal fundal pressure from the other hand or an assistant, as needed
(figure 2). The shoulders are then delivered using gentle traction to guide one,
and then the other, through the hysterotomy, using fundal pressure as needed;
the rest of the body should follow easily.
Extreme prematurity, a deeply impacted or floating fetal head, or an abnormal
lie can make fetal extraction difficult. The approach to difficult fetal extraction is
reviewed separately. (See "Cesarean birth: Management of the deeply
impacted head and the floating head".)
Cord clamping — We delay cord clamping for at least 30 to 60 seconds in
infants who do not require resuscitation. Ideally the cord clamp is applied
following onset of respiration. Delayed, rather than immediate, cord clamping of
vigorous newborns results in higher neonatal hemoglobin levels and iron stores
and facilitates the fetal to neonatal transition. It appears to be particularly
beneficial for preterm newborns, but is recommended for term newborns as
well. The major disadvantage is an increased need for phototherapy for
jaundice. (See "Labor and delivery: Management of the normal third stage after
vaginal birth", section on 'Early versus delayed cord clamping'.)
Care of the newborn — An appropriately trained clinician should be present to
care for the newborn [49]. The degree of training depends on the risk for
neonatal complications. (See "Overview of the routine management of the
healthy newborn infant".)
Early skin to skin contact between mother and newborn appears to promote
breastfeeding and may help with physiological stabilization [50].
Placental extraction — We do not drain any residual blood in the placenta and
cord before extraction. There is only limited evidence that it is beneficial: In a
small trial, draining the placenta passively or actively prior to extraction resulted
in less fetomaternal transfusion [51]. However, the clinical significance of this
finding (ie, frequency of alloimmunization) was not evaluated.
We suggest gentle traction on the cord and use of oxytocin to enhance uterine
contractile expulsive efforts and allow spontaneous placental expulsion, rather
than manual extraction. In a systematic review of randomized trials, manual
extraction resulted in a higher rate of postoperative endometritis (RR 1.64, 95%
CI 1.42-1.90), greater blood loss (weighted mean difference 94 mL, 95% CI 17-
172 mL), a higher rate of blood loss over 1000 mL (RR 1.81, 95% CI 1.11-2.28),
and lower postpartum hematocrit [52]. It is hypothesized that spontaneous
expulsion allows the uterus time to contract and thus close myometrial sinuses.
It also avoids potential contamination of open sinuses from any bacteria on the
surgeon's gloves, although this does not appear to be clinically significant since
changing gloves before manual removal of the placenta does not reduce the
risk of endometritis [53].
Changing gloves after delivery of the placenta may be considered, based on its
association with a decrease in wound infections in some studies. In a meta-
analysis of randomized trials, changing gloves after placental delivery reduced
wound infections by 60 percent (20 of 332 [6 percent] versus 55 of 346 [16
percent]; RR 0.39, 95% CI 0.24-0.63) [54]. However, the intervention did not
reduce the frequency of postpartum endometritis or febrile morbidity and there
were many limitations to the included trials (eg, lack of adequate methodologic
information, lack of blinding where possible, lack of information about intention-
to-treat and loss to follow up, unclear matching for risk factors such as prelabor
rupture of membranes, active labor versus prelabor cesarean, and cervical
dilation). High-quality, adequately powered randomized trials using a consistent
validated definition of surgical site infection are needed before making a
definitive conclusion regarding the effectiveness of changing gloves to reduce
postpartum infection after cesarean.

To ensure that the entire placenta has been removed, the inside of the uterus is
usually wiped with a gauge sponge to remove any remaining membranes or
placental tissue. This maneuver may also stimulate uterine contraction.

PREVENTION OF POSTPARTUM HEMORRHAGE Uterine

contraction is the main mechanism for reduction of uterine bleeding. Oxytocin is

administered intravenously after delivery of the infant to promote uterine
contraction and involution [1]. The author's practice is to also
administer misoprostol or tranexamic acid [55]. (See "Management of the third
stage of labor: Prophylactic drug therapy to minimize hemorrhage", section on
'Active management' and "Anesthesia for cesarean delivery", section on
'Administration of uterotonics'.)
While we and many other clinicians massage the uterus after delivery until it
becomes firm to reduce the risk of postpartum hemorrhage, no randomized
trials have evaluated the efficacy of massage after cesarean birth [56].
Postpartum hemorrhage is an obstetric emergency. Management is reviewed in
detail separately. (See "Postpartum hemorrhage: Management approaches
requiring laparotomy".)

UTERINE CLOSURE

Our approach — We generally exteriorize the uterus and perform a two-layer,

continuous full-thickness closure with delayed absorbable synthetic suture. The
first layer incorporates the myometrium plus the decidual edge to achieve
hemostasis and the second imbricating layer covers the exposed myometrial
edges. We do not use locking sutures unless arterial bleeding is evident.
Exteriorizing the uterus — Exteriorizing the uterus can improve exposure and
facilitate closure of the hysterotomy. Both personal preference and individual
clinical circumstances should guide this decision.
●In a meta-analysis of randomized trials (20 trials, >20,000
participants) comparing exteriorization with in situ repair,
exteriorization resulted in [57]:
•More patients with intraoperative nausea and vomiting (37.6
percent versus 22.4 percent; odds ratio [OR] 2.09, 95% CI
1.66-2.63)
•No significant difference in perioperative hemoglobin
concentration decrease, estimated blood loss, transfusion
requirement, postoperative nausea and vomiting, duration of
surgery, duration of hospital stay, time to return of bowel
function, fever, endometritis, or wound infection.
•Higher postoperative pain scores at six hours (OR 1.64, 95%
CI 1.31-2.03) with a trend toward increased need for rescue
 analgesia (OR 2.48, 95% CI 0.89-6.90), but similar pain scores
at 24 hours.
A limitation of the analysis is that the effects of prophylactic
interventions to reduce intraoperative nausea and vomiting (eg,
prophylactic phenylephrine infusion and antiemetic drugs) and
postoperative pain, which are components of contemporary
anesthesia practice, could not be evaluated. The effects of the
observed adverse outcomes on maternal satisfaction with the
childbirth experience and initiation of breastfeeding also could not
be evaluated.
Endometrial layer — Whether the endometrium should be included or
excluded from the uterine closure is controversial, with either option probably
reasonable at this time based on available data. Most studies of this issue have
assessed the relationship between closure technique and frequency of
subsequent niche formation. Niche formation is an important outcome because
niches increase the risk of adverse gynecologic and reproductive outcomes (eg,
postmenstrual spotting, dehiscence/rupture, dysmenorrhea, placenta accreta
spectrum, cesarean scar pregnancy).
●A randomized trial of 78 term pregnant patients giving birth by
cesarean supported including the endometrial layer (decidua) in
the full thickness myometrial closure. In this trial, which assigned
participants to a one layer myometrial closure either including or
excluding the endometrial layer, the frequency of a wedge-type
healing defect (niche) on transvaginal ultrasound six weeks
postpartum was significantly lower in the group that had full
thickness suturing (45 versus 69 percent) [58]. Outcomes in
subsequent pregnancies were not evaluated, so the clinical
significance of this finding is unknown.
●Observational data support excluding the endometrial layer
[59,60].
•In one such study, 25 patients at a primary cesarean birth
underwent endometrium-free closure and 20 underwent
closure including endometrium, and all
underwent saline infusion sonohysterogram (SIS) between 6
and 30 months postoperatively [59]. Seventeen patients had
clinically significant niches and the rate was six-fold higher in
those with closures including endometrium (OR 6.0, 95% CI
1.6-22.6), a difference that persisted after controlling for SIS
interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3).
The average niche depth was deepest in patients with single-
layer closure including endometrium (5.7 mm) versus two-layer
closure including endometrium (4.9 mm) and two-layer
endometrium-free closure (2.4 mm). Use of SIS was a strength
of this study, but the small number of patients in each group
and the observational design limit interpretation of the findings.
•In another study of 727 cesarean births performed using an
endometrium-free closure technique with 506 subsequent
pregnancies, no patient had abnormal implantation of the
placenta in a cesarean scar [60].
Needles — Use of blunt (rounded tip) needles during closure is associated with
similar maternal outcomes as use of sharp (tapered point) needles [61], and is
much safer for the surgeon (glove perforation rate RR 0.45, 95% CI 0.37-0.54
[62]).
Choice of suture and technique
●Suture – Choice of suture is largely based on personal
preference. In a large randomized trial (Caesarean section
surgical techniques [CORONIS]), choice of suture material (eg,
chromic catgut versus delayed absorbable synthetic [eg,
polyglactin 910, poliglecaprone 25]) did not result in statistically
significant differences in maternal outcome [29,30].
A 0-delayed absorbable synthetic monofilament (eg, Monocryl) or
braided (eg, Vicryl) suture is commonly used in the United States.
Barbed suture has been used successfully for knotless closure of
myomectomy incisions [63-65] and skin closure of the
Pfannenstiel incision during cesarean birth [66]. Use of barbed
suture for uterine closure appeared to shorten total surgical time
by approximately two minutes and reduce the need for additional
hemostatic sutures (RR 0.39, 95% CI 0.28-0.54) in a meta-
analysis of three small trials, but the level of evidence was low to
very low [67].
Sutures coated with antimicrobial compounds may decrease the
rates of surgical site infection, but randomized trials have reported
discordant results [68], none have been performed in patients
undergoing cesarean birth, and the development of surgical site
infection is multifactorial so manipulation of a single factor (eg,
suture) is not likely to provide a significant benefit for all patients.
(See "Principles of abdominal wall closure", section on 'Triclosan-
coated versus noncoated sutures'.)
●Technique – No convincing evidence is available to guide choice
of technique (eg, continuous [locked or nonlocked] versus
interrupted) [45].
Single- versus double-layer closure of lower uterine segment
incisions — We generally perform a two-layer rather than a single-layer uterine
closure (see 'Our approach' above), but use a single-layer closure when a tubal
ligation is performed concurrently since it saves time and concern about uterine
rupture in a subsequent pregnancy is not an issue. Given the available data
(discussed below), either a one- or two-layer closure technique is within
acceptable standards of medical practice. If a single-layer closure is performed
to save time, we suggest an unlocked technique [69-72]. A double (or even
triple)-layer closure may be necessary when the myometrium is thick, such as
with a classical and some low vertical incisions.
Short-term maternal outcomes are similar for single- and double-layer closure,
except a single-layer closure takes less time. In a 2014 systematic review and
meta-analysis of comparative studies, single- and double-layer hysterotomy
closure resulted in similar rates of overall maternal infectious morbidity,
endometritis, wound infection, and blood transfusion, but operative time was six
minutes shorter with the single-layer closure (20 studies including almost
15,000 patients) [73].
Over the long term, however, uterine rupture in the next pregnancy is a
theoretic concern of single-layer closure. In a 2017 systematic review and meta-
analysis of nine randomized trials (3969 pregnancies), single- and double-layer
uterine incision closure resulted in a similar incidence of cesarean scar defects
(25 and 43 percent, respectively; RR 0.77, 95% CI 0.36-1.64), uterine
dehiscence (0.4 and 0.2 percent, respectively; RR 1.34, 95% CI 0.24-4.82), and
rupture in a subsequent pregnancy (0.1 percent for both; RR 0.52, 95% CI 0.05-
5.53), but single-layer closure resulted in thinner residual myometrial thickness
on postpartum ultrasound (mean difference -2.19 mm, 95% CI -2.80 to -1.57)
[74]. However, available data were of low quality due to imprecision and
indirectness and thus do not provide convincing evidence of safety or harm.
The technique used for the single-layer closure may be a contributing factor.
Compared with an unlocked closure, locked closure has been associated with
higher occurrence of surrogate markers of scar weakness (thinner myometrial
thickness, bell-shaped uterine wall defects) [69,70,75] and dehiscence/rupture
[71]. As discussed above, inclusion of the decidua/endometrium (full thickness
suturing technique) may be another factor that impacts scar strength [58,75].
However, available data are limited by heterogeneity in criteria for diagnosis of
uterine scar defects, length of follow-up, method of follow-up, and closure
technique, as well as lack of randomization for the primary outcome and the low
number of uterine ruptures.
There is also a paucity of data on other long-term outcomes. A secondary
analysis of data from a prospective study of patients undergoing repeat
cesarean birth observed an increased risk of bladder adhesions in patients who
had undergone single-layer closure [76]. Further study of possible adverse
consequences of single-layer closure is warranted.
Closure of a classical incision — No trials have compared techniques for
closure of the thick myometrium of the fundus. We use continuous sutures to
close the inner myometrial layer; others prefer interrupted sutures, including
interrupted vertical figure of eight sutures. It is useful to have an assistant
manually reapproximate the incision by pushing the myometrium on each side
toward the midline as each suture is placed and tied. This reduces tension on
the incision and helps prevent the suture from tearing through the myometrium,
especially when closing the first layer. The mid-portion of the thick myometrial
layer is closed with a second line of sutures, leaving approximately 1 cm of
outer myometrium still open. We then close the serosa and outer layer using a
baseball stitch, which is hemostatic and minimizes exposed raw surfaces, and
thus may reduce adhesions (figure 3). The baseball stitch is a continuous,
unlocked stitch in which the needle is driven through the cut edge of the
myometrium to exit the serosa a few millimeters from the incision for each
needle bite. This brings the serosal surfaces together to cover the infolded
edges of the incision.
Unnecessary procedures
Cervical dilation — Routine manual/instrumental cervical dilatation before
closing the uterus is unnecessary in both laboring and nonlaboring patients.
Meta-analysis of randomized trials has not found that this practice reduces
postoperative morbidity [77].
Uterine irrigation — We do not irrigate the uterus before closure. For
prevention of postoperative infection, there is no strong evidence that uterine
irrigation with an antibiotic solution is more effective or advantageous compared
with preincision parenteral antibiotic prophylaxis [78].

POSTPARTUM CONTRACEPTION For patients who desire an

intrauterine device (IUD) for contraception, the IUD can be placed before or
after closure of the hysterotomy. The procedure and potential complications are
described separately. (See "Postpartum contraception: Counseling and
methods", section on 'Intrauterine devices' and "Intrauterine contraception:
Insertion and removal", section on 'Immediate post-placental insertion'.)
The procedure for permanent contraception is also described separately.
(See "Overview of female permanent contraception" and "Postpartum
permanent contraception: Procedures", section on 'Following cesarean birth'.)

ABDOMINAL WALL CLOSURE The abdominal cavity should be

inspected before closing the abdomen to ensure that hemostasis has been
achieved. Retroperitoneal enlargement or bulging of the broad ligament can be
signs of retroperitoneal hemorrhage; the abdomen should not be closed until
the possibility of ongoing retroperitoneal bleeding has been excluded.
Fascia — The method of fascial closure is a critical aspect of incisional closure,
as the fascial closure provides most of the abdominal wound strength during
healing. Care should be taken to avoid placing too much tension on the fascia
since reapproximation, not strangulation, is the goal. Difficulty with hemostasis
is usually not a major issue. Meta-analyses of randomized trials of closure
of midline fascial incisions suggest the optimal approach involves use of:
●A continuous (not interrupted) technique [79,80]
●Slowly (not rapidly) absorbable suture [79]
●Mass (not layered) closure [80]
●Suture length to wound length ratio of 4 to 1 [80]
Classically, sutures have been placed approximately 1 cm from the edge of the
incision and 1 cm apart, without excessive tension. However, in a large
randomized trial including non-cesarean surgeries (pregnant patients excluded),
a technique of 5 mm tissue bites and 5 mm inter-suture spacing limited to the
aponeurosis and using a 2-0 suture on a small needle resulted in fewer
incisional hernias at one year than the classic 1 cm by 1 cm technique (13
versus 21 percent [35 of 277 versus 57 of 277]; odds ratio [OR] 0.52, 95% CI
0.31-0.87) [81]. We have not changed our midline closure technique as this
approach has not been validated in pregnant patients.
The majority of fascial closures after cesarean birth involve a transverse fascial
incision and few randomized trials have evaluated the optimum closure
technique in this setting. For transverse fascial incisions, a continuous
nonlocking closure with slowly absorbable #0 or 1 braided suture (eg,
polyglactin 910) is a common approach, but a monofilament (eg,
polydioxanone) can also be used [7,82]. A randomized trial of closure
techniques for repair of transverse incisions of abdominal fascia in rabbits found
that interrupted closure had a greater maximum tensile strength than
continuous closure during the first two postoperative weeks, but both repair
methods had similar maximum tensile strength at four postoperative weeks [83].
(See "Principles of abdominal wall closure", section on
'Fascia' and "Complications of abdominal surgical incisions", section on
'Prevention'.)
Subcutaneous tissue — Subcutaneous tissue closure appears to benefit some
patients undergoing cesarean birth, but available evidence is low quality [84].
We close the subcutaneous adipose layer with interrupted delayed-absorbable
sutures if the layer is ≥2 cm thick [85,86]. In a 2004 meta-analysis of
randomized trials, suture closure of the subcutaneous adipose layer at
cesarean birth decreased the risk of subsequent wound disruption by one-third
in patients with subcutaneous tissue depth ≥2 cm, but not in those <2 cm [86].
Closure of the dead space seems to inhibit accumulation of serum and blood,
which can lead to a wound seroma or hematoma and subsequent wound
breakdown [86,87]. This occurrence is a major cause of morbidity, can be
costly, and lengthens recovery time. Although placing suture material in the
subcutaneous tissue theoretically could increase the risk of wound infection, an
increase has not been documented [84,85].
Unnecessary procedures
Abdominal irrigation — We do not irrigate the abdomen before closing the
abdominal wall. In randomized trials, intraabdominal irrigation did not reduce
maternal infectious morbidity beyond the reduction achieved with prophylactic
intravenous antibiotics alone, and substantially increased the frequency of
intraoperative nausea and vomiting and postoperative nausea [88].
Wound irrigation — Irrigation before closure of the subcutaneous tissues at
cesarean birth did not reduce the rate of surgical site infection in two
randomized trials [89,90] and is probably unnecessary after routine intravenous
antibiotic prophylaxis.
Irrigation has also been proposed to remove any endometrial cell contamination
and thus reduce the risk of development of an incisional endometrioma. This
disorder is uncommon (incidence after cesarean 0.03 to 0.45 percent) [91]. The
efficacy of irrigation of the subcutaneous tissues at cesarean has not been
studied; the author does not perform it.
Adhesion barriers — The body of available evidence does not support the
routine use of adhesion barriers in patients undergoing cesarean birth [92-94].
Formation of adhesions is common after cesarean birth; rates of 11 to 70
percent have been reported [95]. The rate of bowel obstruction after cesarean
birth is much lower, ranging from 0.5 to 9 per 1000 cesarean births, with the
highest risk in patients who have undergone multiple cesarean births [95-97].
It has been estimated that patients increase their risk of small bowel obstruction
by 0.1 percent by undergoing cesarean birth and that adhesion barriers may
mitigate this risk by 50 percent [98]. Based on these assumptions, 2000 patients
would need to have an adhesion barrier placed at cesarean birth to avoid one
bowel obstruction and the cost per small bowel obstruction averted would be
several hundred thousand dollars. In the only randomized trial, 753 patients
undergoing primary or repeat cesarean birth were assigned to receive or not
receive an adhesion barrier (sodium hyaluronic acid-carboxymethylcellulose)
[99]. At the subsequent delivery (172 participants), 76 percent of patients in
both groups had adhesions; severe adhesions were more common in the
barrier group (33.3 versus 15.5 percent). Neither group experienced a bowel
obstruction.
Reapproximation of the peritoneum — We do not close the visceral or
parietal peritoneum because it saves time and there is no convincing evidence
of harm (such as increased adhesion formation) from not closing the
peritoneum.
In a 2014 meta-analysis of randomized trials, visceral and peritoneal non-
closure decreased operative time by an average of approximately 6 minutes
[100]. In addition, a large, well-designed trial that randomly assigned 533
patients at primary cesarean to peritoneal non-closure or closure found no
significant difference between groups in the proportion of patients with
adhesions at any site or time from incision to delivery at repeat cesarean (n =
97 repeat cesareans) [101]. Strengths of this trial include that its primary
objective was to examine adhesion formation at a repeat cesarean birth, use of
an adhesion scoring system, exclusion of patients who had had prior pelvic or
abdominal surgery, use of a standard technique for performing the cesareans,
and blinding the surgeon performing the repeat cesarean to patient allocation.
However, the effect of non-closure on adhesion formation remains unclear
because of the small number of patients who have undergone follow-up at a
second cesarean birth. Non-closure might allow the enlarged uterus to adhere
to the anterior abdominal wall or impede spontaneous closure of the
peritoneum, while closure might cause a foreign body reaction to sutures and
tissue damage. In a 2009 systematic review of prospective observational
studies of peritoneal non-closure at cesarean birth, non-closure was associated
with greater adhesion formation than closure of the parietal layer or both
visceral and parietal layers (OR 2.6, 95% CI 1.48-4.56; three studies, n = 249)
[102]. The studies were included if the primary objective was to examine
adhesion formation at a repeat cesarean birth, had a clear study design, had an
adhesion scoring system, and excluded patients who had adhesions at the
primary cesarean or who had interim surgeries after the primary cesarean.
Many studies were excluded from this review because of poor methodologic
design or clinical heterogeneity. However, a 2011 systematic review that
included many of these excluded observational studies also found that non-
closure was associated with greater adhesion formation [103].
Reapproximation of rectus muscles — We and most other clinicians believe
that the rectus muscles reapproximate naturally and suturing them together may
cause unnecessary pain when the patient starts to move after surgery [11]. No
randomized trial has evaluated rectus muscle closure versus non-closure. A
prospective observational study reported a reduction in dense adhesion
formation when the rectus muscles were reapproximated; however, this study
did not assess pain or hematoma formation potentially related to this
intervention and could not fully adjust for other intraoperative interventions, such
as peritoneal closure [104].
Drains — In a 2013 meta-analysis of randomized trials of wound drainage at
cesarean birth, routine use of wound drains was not beneficial [105]. Compared
with no drain, routine use of drains does not reduce the odds of seroma,
hematoma, infection, or wound disruption. Additionally, restricted use of
subrectus sheath drains offers no benefit in maternal infectious morbidity
compared with liberal use [106]. These findings also apply to patients with
obesity [107].
 SKIN CLOSURE We prefer to reapproximate the skin with

subcuticular suture rather than staples. In a 2015 meta-analysis of randomized

trials, patients whose incisions were closed with suture had fewer wound
complications than those closed with staples (relative risk [RR] 0.49, 95% CI
0.28-0.87) [108]. The decrease in wound complications was largely due to fewer
wound separations with sutured closure (RR 0.29, 95% CI 0.20-0.43);
differences in infection, hematoma, seroma, and readmission rates were not
significant. Cosmetic appearance, pain perception at discharge, and patient
satisfaction were similar for both approaches. Suture placement took 7 minutes
longer than stapled closure. The staples were removed within 4 days of surgery
in many trials. Delaying removal may reduce the risk of separation, but the time
involved to remove staples before or after hospital discharge also needs to be
considered.
The best type of suture is unclear; most surgeons use poliglecaprone
(monofilament) or polyglactin (braided). A randomized trial of 275 patients who
underwent scheduled or nonemergent cesarean birth through a Pfannenstiel
skin incision found that poliglecaprone 25 resulted in a lower rate of overall
wound complications compared with polyglactin 910 (8.8 versus 14.4 percent,
RR 0.61, 95% CI 0.37-0.99), but the wide confidence interval in this trial, as well
as the lack of other randomized trials of this issue, preclude making a strong
recommendation for one suture over the other at this time. Barbed sutures
reduce closure time and may result in a better cosmetic appearance, but data
are limited and not from trials of cesarean birth [109-112].

DRESSING Postoperative surgical incisions (clean, clean-

contaminated) are typically covered with a dry dressing that is held in place with
an adhesive (eg, tape, Tegaderm). The choice of wound dressing depends
primarily on the surgeon's preference. A systematic review concluded that the
available evidence did not support a recommendation for any particular type of
wound dressing nor whether covering surgical wounds reduced the risk for
infection [113]. For patients undergoing cesarean birth, advanced dressings
(hydrogel, hydrocolloid, alginate, film, soft polymer, capillary-acting, odor
absorbent, or antimicrobial dressing) do not prevent more surgical site
infections than simple dressings (basic wound contact or gauze dressing) [114].
(See "Overview of control measures for prevention of surgical site infection in
adults", section on 'Intraoperative wound protectors' and "Basic principles of
wound management", section on 'Wound dressings'.)

ALTERNATIVE TECHNIQUES Several techniques to simplify the

surgical approach, decrease operating time, and reduce postoperative morbidity

have been proposed. It is impossible to assess which technical aspects of a
particular method of cesarean birth are clearly advantageous because several
aspects of the method are studied at the same time [115]. Furthermore, long-
term outcomes have not been adequately evaluated.
The Pelosi [27] and Misgav Ladach (also known as modified Joel-Cohen or
Joel-Cohen-Stark) (table 1) [21,22] approaches have incorporated many
modifications of standard and Joel-Cohen techniques. As discussed above, the
Joel-Cohen type incision is associated with less fever, pain, use of analgesia,
blood loss, operating time, and hospital days compared with the standard
Pfannenstiel incision (see 'Skin incision' above) and, in one randomized trial,
the Joel-Cohen/Misgav Ladach method resulted in fewer patients with
intraperitoneal adhesions at repeat cesarean birth (11 percent versus 36
percent after standard Pfannenstiel-Kerr approach) [116].
The Pelosi technique is illustrated by the following photographs (picture 1A-C,
1C-D). There are no randomized trials comparing the Pelosi technique with
other techniques.

SPECIAL POPULATIONS

Patients with obesity — Specific issues for cesarean birth of patients with
obesity are reviewed separately. (See "Cesarean birth: Overview of issues for
patients with obesity" and "Obesity in pregnancy: Complications and maternal
management".)

INCIDENTAL FINDINGS AND PROCEDURES

Bandl's ring — Bandl's ring is a pathologic constriction that forms between the
thickened upper contractile portion of the uterus and the thinned lower uterine
segment as a result of dystocia. It is rare and often leads to cesarean birth
because of a prolonged second stage of labor. At laparotomy, the upper and
lower segments of the uterus are separated by a transverse thickened muscular
band. The band may trap the head or shoulders, making fetal extraction at
cesarean difficult. In twin gestations, a Bandl ring can cause dystocia of the
second twin.
If the fetus is difficult to extract, nitroglycerin intravenously may relax the uterus
and facilitate delivery [117-119]. A vertical myometrial incision through the ring
has also been recommended, but transecting the ring alone may not allow easy
delivery of the fetus.
Tubal sterilization — Sterilization can be performed at cesarean birth.
(See "Postpartum permanent contraception: Procedures".)
Myomectomy — Myomectomy should not be performed at cesarean birth
unless the procedure cannot be safely delayed. (See "Uterine fibroids
(leiomyomas): Issues in pregnancy", section on 'Indications for antepartum
abdominal myomectomy'.)
Adnexal mass — Any adnexal mass that appears suspicious for malignancy
should be removed and sent for frozen section. (See "Adnexal mass in
pregnancy", section on 'Adnexal mass at cesarean delivery'.)
Appendectomy — We recommend not performing elective appendectomy at
cesarean birth. It lengthens operative time and there is no strong evidence of
benefit, but it also does not appear to be harmful [120].
Hernia repair — Although combined cesarean birth and hernia repair have
been reported [121,122], planned hernia repair should generally be deferred for
at least four weeks postpartum to allow the lax abdominal wall to return to its
baseline. (See "Overview of treatment for inguinal and femoral hernia in
adults".)

SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Cesarean birth".)

INFORMATION FOR PATIENTS UpToDate offers two types of

patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5 th to 6th grade
reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10 th to 12th grade reading level and are
best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: C-section (cesarean birth)

(The Basics)")
●Beyond the Basics topics (see "Patient education: C-section
(cesarean delivery) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Opening the abdomen

•For the initial incision opening the abdomen, we suggest a
transverse (eg, Pfannenstiel or Joel-Cohen) rather than a
vertical skin incision (Grade 2C). A transverse incision is
associated with better cosmetic appearance and possibly less
postoperative pain and greater wound strength than the
vertical midline incision. However, the incision to delivery time
appears to be approximately one minute faster with vertical
skin incisions. (See 'Choice of incision' above.)
•A scalpel or electrocautery can be used for tissue dissection,
based on the surgeon's preference. (See 'Scalpel or
electrocautery?' above.)
 •The fascial incision can be extended sharply or bluntly.
(See 'Fascial layer' above.)
•We leave the rectus muscles intact rather than using the
Maylard technique. This improves abdominal muscle strength
in the short-term. (See 'Rectus muscle layer' above.)
•We use fingers to bluntly open the peritoneum to minimize the
risk of inadvertent injury to bowel, bladder, or other organs that
may be adherent to the underlying surface. However, a sharp
technique is also acceptable. (See 'Opening the
peritoneum' above.)
●Bladder flap – We do not routinely create a bladder flap. This
saves time and reduces blood loss. (See 'Bladder flap' above.)
●Hysterotomy
•For the hysterotomy, we suggest a low transverse rather than
a low vertical incision for most patients (Grade 2C). The low
transverse incision is associated with less blood loss, less
need for bladder dissection, is easier to reapproximate, and
has a lower risk of rupture in subsequent pregnancies.
However, a low vertical hysterotomy is preferable in some
settings, such as a poorly developed lower uterine segment or
lower uterine segment pathology. It also is preferable for
delivery of a very large fetus (eg, anomalous, extreme
macrosomia) when there is high risk of extension of a
transverse incision into uterine vessels or a T or J extension
may be required to extract the fetus.
(See 'Hysterotomy' above.)
•We suggest blunt rather than sharp expansion of the
hysterotomy incision (Grade 2B). Blunt expansion is quick and
has less risk of inadvertent trauma to the fetus, and may
reduce blood loss and extension of the incision.
(See 'Hysterotomy' above.)
●Placental extraction – We recommend spontaneous, rather
than manual, extraction of the placenta (Grade 1A). Spontaneous
extraction is associated with lower rates of endometritis and
bleeding. (See 'Placental extraction' above.)
●Uterine closure – Exteriorization or non-exteriorization of the
uterus are both acceptable approaches. The choice depends on
personal preference and the clinical setting. (See 'Exteriorizing the
uterus' above.)
For patients who would consider a trial of labor after a previous
cesarean birth, we suggest a two-layer uterine closure rather than
a one-layer closure (Grade 2C). If a single layer closure is
performed, we suggest an unlocked closure (Grade 2C).
(See 'Single- versus double-layer closure of lower uterine segment
incisions' above.)
●Closing the abdomen
•In patients who have received standard antibiotic prophylaxis,
abdominal irrigation probably does not further reduce maternal
infectious morbidity. Wound irrigation is also unlikely to be
 beneficial. (See 'Abdominal irrigation' above
and 'Subcutaneous tissue' above.)
•We suggest not closing the visceral or parietal peritoneum
(Grade 2B). Non-closure saves time and there is no
convincing evidence of harm (increased adhesion formation).
(See 'Reapproximation of the peritoneum' above.)
•For patients with subcutaneous tissue depth ≥2 cm, we
recommend closure of the subcutaneous tissue layer with
sutures (Grade 1A). Closure decreases the risk of subsequent
wound disruption. (See 'Subcutaneous tissue' above.)
•We recommend not routinely placing a subcutaneous drain
(Grade 1B). Routine use of drains does not reduce the odds of
seroma, hematoma, infection, or wound disruption.
(See 'Drains' above.)
•We suggest reapproximation of the skin with subcuticular
suture rather than staples (Grade 2C), but either technique is
reasonable. (See 'Skin closure' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Temmerman M. Caesarean section surgical techniques: all equally safe.
Lancet 2016; 388:8.
2. Wilson RD, Caughey AB, Wood SL, et al. Guidelines for Antenatal and
Preoperative care in Cesarean Delivery: Enhanced Recovery After
Surgery Society Recommendations (Part 1). Am J Obstet Gynecol
2018; 219:523.e1.
3. Caughey AB, Wood SL, Macones GA, et al. Guidelines for intraoperative
care in cesarean delivery: Enhanced Recovery After Surgery Society
Recommendations (Part 2). Am J Obstet Gynecol 2018; 219:533.
4. Macones GA, Caughey AB, Wood SL, et al. Guidelines for postoperative
care in cesarean delivery: Enhanced Recovery After Surgery (ERAS)
Society recommendations (part 3). Am J Obstet Gynecol 2019;
221:247.e1.
5. ACOG Committee Opinion No. 750: Perioperative Pathways: Enhanced
Recovery After Surgery. Obstet Gynecol 2018; 132:e120.
6. Bollag L, Lim G, Sultan P, et al. Society for Obstetric Anesthesia and
Perinatology: Consensus Statement and Recommendations for
Enhanced Recovery After Cesarean. Anesth Analg 2021; 132:1362.
7. Seiler CM, Deckert A, Diener MK, et al. Midline versus transverse
incision in major abdominal surgery: a randomized, double-blind
equivalence trial (POVATI: ISRCTN60734227). Ann Surg 2009;
249:913.
8. Brown SR, Goodfellow PB. Transverse verses midline incisions for
abdominal surgery. Cochrane Database Syst Rev 2005; :CD005199.
9. Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Up and down or side
to side? A systematic review and meta-analysis examining the impact of
incision on outcomes after abdominal surgery. Am J Surg 2013;
206:400.
10. Wylie BJ, Gilbert S, Landon MB, et al. Comparison of transverse and
vertical skin incision for emergency cesarean delivery. Obstet Gynecol
2010; 115:1134.
11. Dahlke JD, Mendez-Figueroa H, Rouse DJ, et al. Evidence-based
surgery for cesarean delivery: an updated systematic review. Am J
Obstet Gynecol 2013; 209:294.
12. Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean
section. Cochrane Database Syst Rev 2007; :CD004453.
13. Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for cesarean
section. Am J Obstet Gynecol 2009; 201:431.
14. Gizzo S, Andrisani A, Noventa M, et al. Caesarean section: could
different transverse abdominal incision techniques influence postpartum
pain and subsequent quality of life? A systematic review. PLoS One
2015; 10:e0114190.
15. Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for
caesarean section. Cochrane Database Syst Rev 2013; :CD004453.
16. Aird LN, Brown CJ. Systematic review and meta-analysis of
electrocautery versus scalpel for surgical skin incisions. Am J Surg
2012; 204:216.
17. Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of
cutting diathermy versus scalpel for skin incision. Br J Surg 2012;
99:613.
18. Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical
scalpel or diathermy in making abdominal skin incisions. Ann Surg
2011; 253:8.
19. Elbohoty AE, Gomaa MF, Abdelaleim M, et al. Diathermy versus scalpel
in transverse abdominal incision in women undergoing repeated
cesarean section: A randomized controlled trial. J Obstet Gynaecol Res
2015; 41:1541.
20. Hasselgren PO, Hagberg E, Malmer H, et al. One instead of two knives
for surgical incision. Does it increase the risk of postoperative wound
infection? Arch Surg 1984; 119:917.
21. Holmgren G, Sjöholm L, Stark M. The Misgav Ladach method for
cesarean section: method description. Acta Obstet Gynecol Scand
1999; 78:615.
22. Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery.
Br J Obstet Gynaecol 1999; 106:221.
23. Aabakke AJ, Hare KJ, Krebs L, Secher NJ. Sharp compared with blunt
fascial incision at cesarean delivery: a randomized controlled trial with
each case as her own control. Eur J Obstet Gynecol Reprod Biol 2014;
172:40.
24. Berthet J, Peresse JF, Rosier P, Racinet C. [Comparative study of
Pfannenstiel's incision and transverse abdominal incision in gynecologic
and obstetric surgery]. Presse Med 1989; 18:1431.
25. Giacalone PL, Daures JP, Vignal J, et al. Pfannenstiel versus Maylard
incision for cesarean delivery: A randomized controlled trial. Obstet
Gynecol 2002; 99:745.
26. Ayers JW, Morley GW. Surgical incision for cesarean section. Obstet
Gynecol 1987; 70:706.
27. Wood RM, Simon H, Oz AU. Pelosi-type vs. traditional cesarean
delivery. A prospective comparison. J Reprod Med 1999; 44:788.
28. Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the
rectus sheath necessary during Pfannenstiel incision for lower segment
Caesarean section? A randomised controlled trial. Eur J Obstet Gynecol
Reprod Biol 2006; 128:262.
29. CORONIS Collaborative Group, Abalos E, Addo V, et al. Caesarean
section surgical techniques (CORONIS): a fractional, factorial,
unmasked, randomised controlled trial. Lancet 2013; 382:234.
30. CORONIS collaborative group, Abalos E, Addo V, et al. Caesarean
section surgical techniques: 3 year follow-up of the CORONIS
fractional, factorial, unmasked, randomised controlled trial. Lancet 2016;
388:62.
31. Tappauf C, Schest E, Reif P, et al. Extraperitoneal versus
transperitoneal cesarean section: a prospective randomized comparison
of surgical morbidity. Am J Obstet Gynecol 2013; 209:338.e1.
32. Hibbard LT. Extraperitoneal cesarean section. Clin Obstet Gynecol
1985; 28:711.
33. Kroon N, Reginald PW. Parietal peritoneal closure at caesarean section
revisited. J Obstet Gynaecol 2007; 27:159.
34. O'Neill HA, Egan G, Walsh CA, et al. Omission of the bladder flap at
caesarean section reduces delivery time without increased morbidity: a
meta-analysis of randomised controlled trials. Eur J Obstet Gynecol
Reprod Biol 2014; 174:20.
35. O'Boyle AL, Mulla BM, Lamb SV, et al. Urinary symptoms after bladder
flap at the time of primary cesarean delivery: a randomized controlled
trial (RTC). Int Urogynecol J 2018; 29:223.
36. Luthra G, Gawade P, Starikov R, Markenson G. Uterine incision-to-
delivery interval and perinatal outcomes in transverse versus vertical
incisions in preterm cesarean deliveries. J Matern Fetal Neonatal Med
2013; 26:1788.
37. Schutterman EB, Grimes DA. Comparative safety of the low transverse
versus the low vertical uterine incision for cesarean delivery of breech
infants. Obstet Gynecol 1983; 61:593.
38. Rashid M, Rashid M. Accidental delivery of a baby during a caesarean
section through a vaginal incision (a laparoelytrotomy). BMJ Case Rep
2010; 2010.
39. Porter S, Paterson-Brown S. Avoiding inadvertent laparoelytrotomy.
BJOG 2003; 110:91.
40. Pereira N, Rasner JN, Brannon RK, Green MA. Inadvertent vaginal
entry during cesarean delivery: a report of two cases. J Reprod Med
2014; 59:429.
41. Shipp TD, Zelop CM, Repke JT, et al. Intrapartum uterine rupture and
dehiscence in patients with prior lower uterine segment vertical and
transverse incisions. Obstet Gynecol 1999; 94:735.
42. Patterson LS, O'Connell CM, Baskett TF. Maternal and perinatal
morbidity associated with classic and inverted T cesarean incisions.
Obstet Gynecol 2002; 100:633.
43. Magann EF, Chauhan SP, Bufkin L, et al. Intra-operative haemorrhage
by blunt versus sharp expansion of the uterine incision at caesarean
delivery: a randomised clinical trial. BJOG 2002; 109:448.
44. Pergialiotis V, Mitsopoulou D, Biliou E, et al. Cephalad-caudad versus
transverse blunt expansion of the low transverse hysterotomy during
cesarean delivery decreases maternal morbidity: a meta-analysis. Am J
Obstet Gynecol 2021; 225:128.e1.
45. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for
uterine incision and uterine closure at the time of caesarean section.
Cochrane Database Syst Rev 2014; :CD004732.
46. Andersen HF, Auster GH, Marx GF, Merkatz IR. Neonatal status in
relation to incision intervals, obstetric factors, and anesthesia at
cesarean delivery. Am J Perinatol 1987; 4:279.
47. Fontanarosa M, Fontanarosa N. Incision-to-delivery interval and
neonatal wellbeing during cesarean section. Minerva Ginecol 2008;
60:23.
48. Bader AM, Datta S, Arthur GR, et al. Maternal and fetal catecholamines
and uterine incision-to-delivery interval during elective cesarean. Obstet
Gynecol 1990; 75:600.
49. Gordon A, McKechnie EJ, Jeffery H. Pediatric presence at cesarean
section: justified or not? Am J Obstet Gynecol 2005; 193:599.
50. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin
contact for mothers and their healthy newborn infants. Cochrane
Database Syst Rev 2016; 11:CD003519.
51. Leavitt BG, Huff DL, Bell LA, Thurnau GR. Placental drainage of fetal
blood at cesarean delivery and feto maternal transfusion: a randomized
controlled trial. Obstet Gynecol 2007; 110:608.
52. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the
placenta at caesarean section. Cochrane Database Syst Rev 2008;
:CD004737.
53. Atkinson MW, Owen J, Wren A, Hauth JC. The effect of manual
removal of the placenta on post-cesarean endometritis. Obstet Gynecol
1996; 87:99.
54. Narice BF, Almeida JR, Farrell T, Madhuvrata P. Impact of changing
gloves during cesarean section on postoperative infective
complications: A systematic review and meta-analysis. Acta Obstet
Gynecol Scand 2021; 100:1581.
55. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for
preventing postpartum haemorrhage: a network meta-analysis.
Cochrane Database Syst Rev 2018; 12:CD011689.
56. Saccone G, Caissutti C, Ciardulli A, Berghella V. Uterine massage for
preventing postpartum hemorrhage at cesarean delivery: Which
evidence? Eur J Obstet Gynecol Reprod Biol 2018; 223:64.
57. Tan HS, Taylor CR, Sharawi N, et al. Uterine exteriorization versus in
situ repair in Cesarean delivery: a systematic review and meta-analysis.
Can J Anaesth 2022; 69:216.
58. Yazicioglu F, Gökdogan A, Kelekci S, et al. Incomplete healing of the
uterine incision after caesarean section: Is it preventable? Eur J Obstet
Gynecol Reprod Biol 2006; 124:32.
59. Antoine C, Meyer JA, Silverstein JS, et al. The Impact of Uterine
Incision Closure Techniques on Post-cesarean Delivery Niche
Formation and Size: Sonohysterographic Examination of Nonpregnant
Women. J Ultrasound Med 2022; 41:1763.
60. Antoine C, Pimentel RN, Reece EA, Oh C. Endometrium-free uterine
closure technique and abnormal placental implantation in subsequent
pregnancies. J Matern Fetal Neonatal Med 2021; 34:2513.
61. Stafford MK, Pitman MC, Nanthakumaran N, Smith JR. Blunt-tipped
versus sharp-tipped needles: wound morbidity. J Obstet Gynaecol
1998; 18:18.
62. Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp
suture needles for preventing percutaneous exposure incidents in
surgical staff. Cochrane Database Syst Rev 2011; :CD009170.
63. Alessandri F, Remorgida V, Venturini PL, Ferrero S. Unidirectional
barbed suture versus continuous suture with intracorporeal knots in
laparoscopic myomectomy: a randomized study. J Minim Invasive
Gynecol 2010; 17:725.
64. Greenberg JA, Einarsson JI. The use of bidirectional barbed suture in
laparoscopic myomectomy and total laparoscopic hysterectomy. J
Minim Invasive Gynecol 2008; 15:621.
65. Peleg D, Ahmad RS, Warsof SL, et al. A randomized clinical trial of
knotless barbed suture vs conventional suture for closure of the uterine
incision at cesarean delivery. Am J Obstet Gynecol 2018; 218:343.e1.
66. Murtha AP, Kaplan AL, Paglia MJ, et al. Evaluation of a novel technique
for wound closure using a barbed suture. Plast Reconstr Surg 2006;
117:1769.
67. Agarwal S, D'Souza R, Ryu M, Maxwell C. Barbed vs conventional
suture at cesarean delivery: A systematic review and meta-analysis.
Acta Obstet Gynecol Scand 2021; 100:1010.
68. Onesti MG, Carella S, Scuderi N. Effectiveness of antimicrobial-coated
sutures for the prevention of surgical site infection: a review of the
literature. Eur Rev Med Pharmacol Sci 2018; 22:5729.
69. Yasmin S, Sadaf J, Fatima N. Impact of methods for uterine incision
closure on repeat caesarean section scar of lower uterine segment. J
Coll Physicians Surg Pak 2011; 21:522.
70. Ceci O, Cantatore C, Scioscia M, et al. Ultrasonographic and
hysteroscopic outcomes of uterine scar healing after cesarean section:
comparison of two types of single-layer suture. J Obstet Gynaecol Res
2012; 38:1302.
71. Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer
closure of the hysterotomy incision during cesarean delivery and risk of
uterine rupture. Int J Gynaecol Obstet 2011; 115:5.
72. Bennich G, Rudnicki M, Wilken-Jensen C, et al. Impact of adding a
second layer to a single unlocked closure of a Cesarean uterine
incision: randomized controlled trial. Ultrasound Obstet Gynecol 2016;
47:417.
73. Roberge S, Demers S, Berghella V, et al. Impact of single- vs double-
layer closure on adverse outcomes and uterine scar defect: a
systematic review and metaanalysis. Am J Obstet Gynecol 2014;
211:453.
74. Di Spiezio Sardo A, Saccone G, McCurdy R, et al. Risk of Cesarean
scar defect following single- vs double-layer uterine closure: systematic
review and meta-analysis of randomized controlled trials. Ultrasound
Obstet Gynecol 2017; 50:578.
75. Stegwee SI, Jordans I, van der Voet LF, et al. Uterine caesarean
closure techniques affect ultrasound findings and maternal outcomes: a
systematic review and meta-analysis. BJOG 2018; 125:1097.
76. Blumenfeld YJ, Caughey AB, El-Sayed YY, et al. Single- versus double-
layer hysterotomy closure at primary caesarean delivery and bladder
adhesions. BJOG 2010; 117:690.
77. Liabsuetrakul T, Peeyananjarassri K. Mechanical dilatation of the cervix
during elective caeserean section before the onset of labour for
reducing postoperative morbidity. Cochrane Database Syst Rev 2018;
8:CD008019.
78. Nabhan AF, Allam NE, Hamed Abdel-Aziz Salama M. Routes of
administration of antibiotic prophylaxis for preventing infection after
caesarean section. Cochrane Database Syst Rev 2016; :CD011876.
79. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy
closure: the INLINE systematic review and meta-analysis. Ann Surg
2010; 251:843.
80. Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an
evidence-based review of the literature. Curr Surg 2005; 62:220.
81. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus
large bites for closure of abdominal midline incisions (STITCH): a
double-blind, multicentre, randomised controlled trial. Lancet 2015;
386:1254.
82. Rahbari NN, Knebel P, Diener MK, et al. Current practice of abdominal
wall closure in elective surgery - Is there any consensus? BMC Surg
2009; 9:8.
83. Maxwell GL, Soisson AP, Brittain PC, et al. Repair of transversely
incised abdominal wall fascia in a rabbit model. Obstet Gynecol 1996;
87:65.
84. Pergialiotis V, Prodromidou A, Perrea DN, Doumouchtsis SK. The
impact of subcutaneous tissue suturing at caesarean section on wound
complications: a meta-analysis. BJOG 2017; 124:1018.
85. Anderson ER, Gates S. Techniques and materials for closure of the
abdominal wall in caesarean section. Cochrane Database Syst Rev
2004; :CD004663.
86. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of
subcutaneous fat and wound disruption after cesarean delivery: a meta-
analysis. Obstet Gynecol 2004; 103:974.
87. Naumann RW, Hauth JC, Owen J, et al. Subcutaneous tissue
approximation in relation to wound disruption after cesarean delivery in
obese women. Obstet Gynecol 1995; 85:412.
88. Eke AC, Shukr GH, Chaalan TT, et al. Intra-abdominal saline irrigation
at cesarean section: a systematic review and meta-analysis. J Matern
Fetal Neonatal Med 2016; 29:1588.
89. Aslan Çetin B, Aydogan Mathyk B, Barut S, et al. The impact of
subcutaneous irrigation on wound complications after cesarean
 sections: A prospective randomised study. Eur J Obstet Gynecol
Reprod Biol 2018; 227:67.
90. Güngördük K, Asicioglu O, Celikkol O, et al. Does saline irrigation
reduce the wound infection in caesarean delivery? J Obstet Gynaecol
2010; 30:662.
91. Zhang P, Sun Y, Zhang C, et al. Cesarean scar endometriosis:
presentation of 198 cases and literature review. BMC Womens Health
2019; 19:14.
92. Edwards RK, Ingersoll M, Gerkin RD, et al. Carboxymethylcellulose
adhesion barrier placement at primary cesarean delivery and outcomes
at repeat cesarean delivery. Obstet Gynecol 2014; 123:923.
93. Gaspar-Oishi M, Aeby T. Cesarean delivery times and adhesion
severity associated with prior placement of a sodium hyaluronate-
carboxycellulose barrier. Obstet Gynecol 2014; 124:679.
94. Walfisch A, Beloosesky R, Shrim A, Hallak M. Adhesion prevention after
cesarean delivery: evidence, and lack of it. Am J Obstet Gynecol 2014;
211:446.
95. Andolf E, Thorsell M, Källén K. Cesarean delivery and risk for
postoperative adhesions and intestinal obstruction: A nested case-
control study of the Swedish Medical Birth Registry. Am J Obstet
Gynecol 2010; 203:406.e1.
96. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated
with multiple repeat cesarean deliveries. Obstet Gynecol 2006;
107:1226.
97. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after
hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
98. Albright CM, Rouse DJ. Adhesion barriers at cesarean delivery:
advertising compared with the evidence. Obstet Gynecol 2011;
118:157.
99. Kiefer DG, Muscat JC, Santorelli J, et al. Effectiveness and short-term
safety of modified sodium hyaluronic acid-carboxymethylcellulose at
cesarean delivery: a randomized trial. Am J Obstet Gynecol 2016;
214:373.e1.
100. Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the
peritoneum at caesarean section: short- and long-term outcomes.
Cochrane Database Syst Rev 2014; :CD000163.
101. Kapustian V, Anteby EY, Gdalevich M, et al. Effect of closure
versus nonclosure of peritoneum at cesarean section on adhesions: a
prospective randomized study. Am J Obstet Gynecol 2012; 206:56.e1.
102. Cheong YC, Premkumar G, Metwally M, et al. To close or not to
close? A systematic review and a meta-analysis of peritoneal non-
closure and adhesion formation after caesarean section. Eur J Obstet
Gynecol Reprod Biol 2009; 147:3.
103. Shi Z, Ma L, Yang Y, et al. Adhesion formation after previous
caesarean section-a meta-analysis and systematic review. BJOG 2011;
118:410.
104. Lyell DJ, Caughey AB, Hu E, et al. Rectus muscle and visceral
peritoneum closure at cesarean delivery and intraabdominal adhesions.
Am J Obstet Gynecol 2012; 206:515.e1.
105. Gates S, Anderson ER. Wound drainage for caesarean section.
Cochrane Database Syst Rev 2013; :CD004549.
106. CAESAR study collaborative group. Caesarean section surgical
techniques: a randomised factorial trial (CAESAR). BJOG 2010;
117:1366.
107. Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue
reapproximation, alone or in combination with drain, in obese women
undergoing cesarean delivery. Obstet Gynecol 2005; 105:967.
108. Mackeen AD, Schuster M, Berghella V. Suture versus staples for
skin closure after cesarean: a metaanalysis. Am J Obstet Gynecol
2015; 212:621.e1.
109. Rubin JP, Hunstad JP, Polynice A, et al. A multicenter randomized
controlled trial comparing absorbable barbed sutures versus
conventional absorbable sutures for dermal closure in open surgical
procedures. Aesthet Surg J 2014; 34:272.
110. Koide S, Smoll NR, Liew J, et al. A randomized 'N-of-1' single
blinded clinical trial of barbed dermal sutures vs. smooth sutures in
elective plastic surgery shows differences in scar appearance two-years
post-operatively. J Plast Reconstr Aesthet Surg 2015; 68:1003.
111. Sah AP. Is There an Advantage to Knotless Barbed Suture in TKA
Wound Closure? A Randomized Trial in Simultaneous Bilateral TKAs.
Clin Orthop Relat Res 2015; 473:2019.
112. Hammond DC. Barbed sutures in plastic surgery: a personal
experience. Aesthet Surg J 2013; 33:32S.
113. Dumville JC, Gray TA, Walter CJ, et al. Dressings for the
prevention of surgical site infection. Cochrane Database Syst Rev 2016;
12:CD003091.
114. Wijetunge S, Hill R, Katie Morris R, Hodgetts Morton V. Advanced
dressings for the prevention of surgical site infection in women post-
caesarean section: A systematic review and meta-analysis. Eur J
Obstet Gynecol Reprod Biol 2021; 267:226.
115. Hofmeyr GJ, Mathai M, Shah A, Novikova N. Techniques for
caesarean section. Cochrane Database Syst Rev 2008; :CD004662.
116. Nabhan AF. Long-term outcomes of two different surgical
techniques for cesarean. Int J Gynaecol Obstet 2008; 100:69.
117. Chedraui PA, Insuasti DF. Intravenous nitroglycerin in the
management of retained placenta. Gynecol Obstet Invest 2003; 56:61.
118. Jha S, Chiu JW, Yeo IS. Intravenous nitro-glycerine versus
general anaesthesia for placental extraction--a sequential comparison.
Med Sci Monit 2003; 9:CS63.
119. Lowenwirt IP, Zauk RM, Handwerker SM. Safety of intravenous
glyceryl trinitrate in management of retained placenta. Aust N Z J
Obstet Gynaecol 1997; 37:20.
120. Pearce C, Torres C, Stallings S, et al. Elective appendectomy at
the time of cesarean delivery: a randomized controlled trial. Am J
Obstet Gynecol 2008; 199:491.e1.
121. Gabriele R, Conte M, Izzo L, Basso L. Cesarean section and
hernia repair: simultaneous approach. J Obstet Gynaecol Res 2010;
36:944.
 122. Ochsenbein-Kölble N, Demartines N, Ochsenbein-Imhof N,
Zimmermann R. Cesarean section and simultaneous hernia repair. Arch
Surg 2004; 139:893.
Topic 5405 Version 126.0
GRAPHICS
Skin incisions for cesarean delivery

The Pfannenstiel skin incision is slightly curved, 2 to 3 cm above the symphysis

pubis, with the midportion of the incision within the clipped area of the pubic
hair. The Joel-Cohen type incision is straight, 3 cm below the line that joins the
anterior superior iliac spines, and slightly more cephalad than Pfannenstiel.
Graphic 113066 Version 1.0
Uncomplicated cesarean delivery of fetus in cephalic
presentation
Graphic 80515 Version 2.0
Baseball stitch
The baseball stitch is a continuous, unlocked stitch in which the needle is driven
through the cut edge of the myometrium to exit the serosa a few millimeters
from the incision for each needle bite. This brings the serosal surfaces together
to cover the infolded edges of the incision.
Graphic 113004 Version 1.0
Misgav Ladach technique (modified Joel-Cohen
technique)
A straight transverse incision is cut only through the skin 3 cm below the level of the anterior superior iliac spines. By c

The subcutaneous tissues in the middle 3 cm of the incision are incised down to the fascia.

The fascia is opened transversely in the midline, and the fascial incision is extended laterally in both directions using sci

The rectus sheath is separated from the rectus muscles by pulling the sheath caudally and cranially using the two index f

The peritoneum is opened by using one or two fingers to perforate the peritoneum and then the opening is stretched by p

All layers of the abdominal wall are manually stretched laterally to both sides to provide an opening as large as the skin

A transverse superficial incision is made through the visceral peritoneum 1 cm above the superior aspect of the bladder.
 A small transverse hysterotomy incision is made and extended laterally to both sides by pulling with the fingers.

The hysterotomy incision is closed with a one-layer continuous locked stitch. A second layer is placed only if needed.

The visceral and parietal peritoneum are not reapproximated.

The fascia is reapproximated with a continuous running stitch.

The skin is reapproximated with 2 or 3 mattress stitches.

A key aspect of the Joel-Cohen approach is minimization of sharp dissection.
Data from: Holmgren G, Sjöholm L, Stark M. The Misgav Ladach method for cesarean
section: method description. Acta Obstet Gynecol Scand 1999; 78:615.
Graphic 70112 Version 5.0
Abdominal incision in the Pelosi technique

(A) A low transverse suprapubic skin incision is made with a scalpel. The
subcutaneous tissue and rectus fascia are incised transversely with
electrocautery knife; the subcutaneous tissue is not stripped from the fascia
beyond what is needed to expose the cut edges of the fascia.
(B) The linea alba is exposed by pulling up the superior edge of the abdominal
incision. The traditional dissection of the superior and inferior aspects of the
fascia from underlying rectus and pyramidal muscles is not routinely performed.
(C) To expose the peritoneum, the rectus muscles are separated in the midline
by vertical digital dissection.
(D) The peritoneum is opened by finger perforation.
(E) The peritoneal opening is then extended digitally by vertical and lateral
traction. When the peritoneum cannot be perforated or stretched digitally, a
scalpel or scissors can be used.
(F) The full thickness of the abdominal incision is then stretched transversely
using the surgeon's fingers.
Courtesy of Marco Pelosi, MD, and Marco Pelosi III, MD.
Graphic 82474 Version 5.0
Placement of the self-retaining abdominal retractor as
part of the Pelosi technique

(A) At left, the protractor (Weck Closure Systems); at right, the Mobius (Apple
Medical Corporation).
(B) The inner ring is squeezed cephalad into the peritoneal cavity.
(C) The inner ring springs open against the parietal peritoneum. A digital check
is performed to assure that no tissue is trapped between the inner ring and the
abdominal wall. The plastic sleeve is then placed on tension.
(D) The outer ring is rolled into the plastic sleeve until the ring completely
inverts.
(E) The result is the creation of an atraumatic, circular, self-retaining area of
retraction.
(F) A small transverse incision is made with the scalpel approximately 1 cm
above the vesicouterine peritoneal fold. The creation of the traditional bladder
flap is avoided.
Courtesy of Marco Pelosi, MD, and Marco Pelosi III, MD.
Graphic 68054 Version 4.0
Delivery and hysterotomy in the Pelosi cesarean
technique

(A) A digital vertical extension of the hysterotomy incision is made. The vertical
extension may be more efficient than traditional transverse extension.
(B) The fetal head is delivered with the support of the surgeon's hand.
(C) When head extraction cannot be accomplished using one hand assisted by
concomitant fundal pressure, the soft vacuum cup can be employed.
(D) Breech delivery is accomplished using standard extraction maneuvers.
(E) Following spontaneous separation, the placenta is removed by fundal
pressure and light cord traction.
(F) The hysterotomy is repaired either in situ using a single-layer closure or by
exteriorizing the uterus and using a double-layer closure. When needed,
hemostatic individual figure-of-eight sutures are also placed.
Courtesy of Marco Pelosi, MD, and Marco Pelosi III, MD.
Graphic 59263 Version 5.0
Closure using Pelosi technique

(A) Exteriorization of the uterus through the abdominal incision is easily

accomplished.
(B) Following completion of the hysterotomy closure, the self-retaining retractor
is removed.
(C) The visceral and parietal peritoneum are not closed.
(D) No suture approximation of the rectus muscles is performed. The fascia is
closed in a continuous, non-locking fashion with delayed-absorbable sutures
placed at least 1 cm from the fascial wound edge (arrows).
(E) The subcutaneous tissue is not closed except when this layer is ≥2 cm
thick. The skin is closed with subcuticular sutures or (F) metal staples.
Courtesy of Marco Pelosi, MD, and Marco Pelosi III, MD.
Graphic 66859 Version 4.0

Contributor Disclosures
Vincenzo Berghella, MDConsultant/Advisory Boards: ProtocolNow [Clinical
guidelines]. All of the relevant financial relationships listed have been mitigated.William
Grobman, MDNo relevant financial relationship(s) with ineligible companies to
disclose.Vanessa A Barss, MD, FACOGNo relevant financial relationship(s) with
ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group.
When found, these are addressed by vetting through a multi-level review process, and
through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to
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