Recommendations with High levels of
Certainty
• Favor:
• Pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine
extension, spontaneous placental removal, surgeon preference on uterine
exteriorization, single-layer uterine closure when future fertility is undesired,
and suture closure of the subcutaneous tissue when thickness is > or =2 cm.
• Do Not Favor:
• Manual cervical dilation, subcutaneous drains, or supplemental oxygen for
the reduction of morbidity from infection.
Preoperative preparation
• Prophylactic antibiotics
• Single dose of Ampicillin or a 1st generation Cephalosporin within 15-60
minutes of incision
• Preoperative vaginal preparation with povidone-iodine scrub
• significantly reduced the incidence of post-cesarean endometritis
Entry
• Joel-Cohen type incisions
• Higher (3cm below the ASIS border)
• Straighter
• mostly blunt dissection to enter the abdomen
• Pfannenstiel type approach (Described in 18
• Curvilinear
• 2-3 cm above the symphysis pubis
• generally involves more sharp dissection
Pfannenstiel vs Joel-Cohen incision
• 3 meta-analyses of randomized trials
• Lower rates of fever, postoperative pain, and use of analgesia;
• Less blood loss (avg -58mL)
• Shorter operating time (avg -11 minutes less)
• Joel-Cohen incision resulted in a 65 percent reduction in reported
postoperative febrile morbidity
Tenets of Halsted
• Gentle handling of tissue
• Meticulous hemostasis
• Preservation of blood supply
• Strict aseptic technique
• Minimum tension on tissues
• Accurate tissue apposition
• Obliteration of deadspace
Bladder Flap
• 2 trials randomized, assigned women to undergo or omit
development of a bladder flap
• (2001) Vienna: reduction of operating time and incision-delivery interval,
reduced blood loss, and need for analgesics. Long-term effects remain to be
evaluated
• (2012) WashU: does not increase intraoperative or postoperative
complications. Incision-to-delivery time is shortened but total operating time
appears unchanged
• May be unavoidable in certain circumstances
Hysterotomy expansion
• Cromi et al. Italy (2008)
• Randomized Controlled trial
• Blunt Cephalad-caudad traction
• Less risk of unintended extension and excessive blood loss compared
with “transversal expansion”
Fetal Extraction
• Usually uncomplicated
• Should be expeditious (uterine incision to delivery)
• Prolongation associated with lower fetal blood gas pH values and
Apgar scores
• Hysterotomy-induced increased uterine tone
Deeply Impacted Fetal Head
• 1.5 % of Cesarean Deliveries
• Fong (Singapore) first described the Reverse Breech extraction
• Levy et al. (2005) compared this…“push” vs “pull”
• ‘Pull' method (Reverse Breech extraction) compared to those that
were delivered by the 'push' method.
• significantly lower rate of postpartum fever
• significantly lower rate extensions of the uterine incision
• Neonatal outcomes were good in all cases
Difficult Extraction
• Adequate abdominal exposure
• Pfannenstiel to Maylard (incision of the rectus muscles)
• Adequate Uterine exposure
• J vs T, extension of classical
• Adequate Anesthesia
• General if necessary
• Uterine Relaxation
• Nitroglycerin 50 micrograms intravenously, can re-dose every 60 seconds, as
needed to achieve adequate uterine relaxation
Prevention of Post Partum Hemorrhage
• Tranexamic Acid
• significantly decreased intraoperative and postpartum blood loss (100-200
mL) in RCT
• Oxytocin
• infusion (10-40 IU in 1 L crystalloid over 4-8 hours) is effective in uterine atony
prevention, with unknown benefit from oxytocin bolus..
Uterine Exteriorization For Repair
• 7 RCT’s, 1 Meta-analysis
• Febrile complications and surgical time were similar between uterine
exteriorization and intraabdominal repair
• Surgeon preference
Uterine Closure
• Single vs double-layer closure / Locked vs Un-locked
• 1 RCT
• Caesarean section surgical techniques: a randomized factorial trial (CAESAR)*.
• 1 metaanalysis
• 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.
Locked or Unlocked
• Single-layer Locked with Chromic, was associated with the highest
uterine rupture risk
• An unlocked single-layer closure with a modern suture material
(vicryl) was Not associated with a significantly higher risk of uterine
rupture or uterine scar dehiscence than a double-layer closure
• Jelsema et al - suggested that an unlocked single-layer closure leads
to better uterine scar healing based on the fact that “locked sutures
increase pressure at the suture–tissue interface, which can cause
ischemic necrosis, impairing coaptation”
Uterine Closure
• “Definitive recommendations regarding subsequent uterine rupture
risk are not possible in women with desired future fertility….In
women with undesired fertility, there does not appear to be any
benefit of a 2-layer uterine closure ”
Peritoneal Closure
• 7 RCT’s, 3 Meta-Analyses
• Parietal, Visceral
• Both, one, or neither
Peritoneal Closure
• A metaanalysis including 4423 women retrospectively evaluated
intraabdominal adhesion formation among 3 different CD surgical
techniques
• Within the cohort of “modified Misgav-Ladach” Non-closure of the
peritoneum demonstrated an increased risk of intraabdominal
adhesions
Fascial Closure
• 1 cm x 1 cm
• Running (continuous – not interrupted), unlocked
• In midline or those at highest risk of incisional hernia or dehiscence
• “Slowly” absorbable suture (preferred over rapidly – Vicryl/Dexon)
Polydioxanone (PDS, MonoPlus) and polyglyconate + trimethylene
carbonate (Maxon)
• Avoid non-absorbable sutures (prolene, ethibond)
