Surgical approaches in Cesarean section
Fetal extraction requires adequate access to the uterus. The choice of laparotomy type is strictly individual and depends on the emergency of the situation, the condition of the abdominal wall (presence of scars), the required scope of the intervention, and the surgeon's skills.
Four main options for opening the anterior abdominal wall are distinguished:
- Lower midline incision (vertically along the linea alba below the umbilicus). Considered the simplest method when surgical experience is insufficient.
- Pfannenstiel incision (arcuate transverse incision above the pubic bone).
- Joel-Cohen incision (straight transverse incision, located higher than the Pfannenstiel incision).
- Midline incision bypassing the umbilicus (3–4 cm above the umbilicus).
It is important to understand that the access on the abdominal wall does not depend on the planned uterine incision. However, in practice, classical Cesarean section is more often performed through a lower midline incision, and transverse incision of the lower segment through Pfannenstiel or Joel-Cohen accesses.
Indications for classical uterine incision
The universally accepted and most rational method worldwide is surgery in the lower uterine segment via a transverse incision. Longitudinal incision of the uterine body along the midline (classical Cesarean section) is extremely rarely used.
Nevertheless, there are strict indications for classical access in which fetal extraction by any other method is impossible or associated with high risks:
- Neglected transverse lie of the fetus.
- Conjoined (undivided) twins.
- Preterm fetus with an unformed lower uterine segment.
- Placenta accreta or uterine aneurysm in the lower segment.
- Pronounced adhesions blocking access to the lower segment.
- Pronounced varicosities in the lower segment area.
- Incompetence of a prior longitudinal scar after a previous classical Cesarean section.
- Need for subsequent removal of the uterus (hysterectomy).
- Presence of a live fetus in a dying woman.
- Lack of skills in lower-segment Cesarean section in the operating physician.
Technique of uterine incision and fetal extraction
During a classical Cesarean section, the uterus is incised strictly along the midline. Since by the end of pregnancy the uterus is often somewhat rotated to the left, it must be rotated around its axis so that the incision line is at an equal distance from both round ligaments.
- Incision: The tissues are deepened with a scalpel along the intended line down to the fetal membranes, then the incision is extended upward and downward with scissors under the control of inserted fingers. The length of the incision must be at least 12 cm, otherwise a short incision will hinder the delivery of the fetus.
- Extraction: The surgeon inserts a hand into the uterine cavity, grasps the presenting part (head or pelvic pole) and extracts it, and then the entire fetus. The amniotic sac is opened with index fingers or a scalpel. The umbilical cord is immediately divided between clamps.
- Medical support: To accelerate placental separation and enhance uterine contractions, oxytocin (5 IU intravenously or into the myometrium) is administered. A broad-spectrum antibiotic is also prescribed intravenously for infection prophylaxis.
Attention: Incision of the uterine body is always accompanied by profuse bleeding, so the stage of fetal extraction must be performed as quickly as possible.
Removal of the placenta and wound closure
After the child is extracted, clamps are applied to the bleeding edges of the uterine wound. The placenta is removed by traction on the umbilical cord. If there is any doubt about the complete removal of placental tissue, manual exploration of the uterine cavity is performed.
In elective Cesarean section (before the onset of labor), the surgeon is obliged to pass an index finger through the internal os of the uterine cervix to ensure drainage. Mandatory condition: the glove must be changed after this.
Suture technique:
- Interrupted holding sutures are applied to the upper and lower angles of the wound (1 cm away from the edge). Their tension ensures good visualization.
- Two-row separate sutures are used to close the wound: the first row is mucosal-muscular (capturing part of the muscle), and the second is serous-muscular. Some specialists consider it necessary to place a third row—a serous-serous suture (peritonization).
- It is advisable to use only synthetic absorbable sutures (Vicryl, Dexon, Monocryl, Polysorb) or chromic catgut. Regular catgut is impractical to use.
The surgery concludes with a mandatory revision of the uterine adnexa, appendix, and adjacent organs, and toilet of the abdominal cavity. Before closing the abdominal wall, the uterus must be firm and contracted.
Briefly: answers to topical questions
What are the classic manual maneuvers for extracting a fetus by the pelvic pole through the natural birth canal?
Classic manual maneuvers are used to maintain the correct fetal attitude and deliver the shoulder girdle and head.
- Tsovyanov manual maneuver — used in frank breech and footling presentations to maintain the normal fetal attitude or retain the feet until full cervical dilation.
- Classic manual maneuver — used to deliver the arms and head of the fetus in the second stage of labor (includes the rule of the homonymous hand).
- Løvset maneuver — used when the arms are nuchal (extended).
- Mauriceau–Smellie–Veit maneuver (Mauriceau-Smellie-Veit) — a classic manual maneuver for delivering the aftercoming fetal head.
How is the grasping and delivery of the fetal pelvic pole technically performed during a Cesarean section?
During a Cesarean section, extraction of the fetus in breech presentation is performed by grasping the inguinal crease or the foot.
- Grasping the inguinal crease — used in breech presentation for fetal extraction.
- Grasping the foot — delivery of the anterior foot of the fetus is performed, followed by the birth of the torso and head.
In a transverse lie, the fetus is also extracted by the foot, and the head is delivered using the Mauriceau–Smellie maneuver. If the head is located high, an internal podalic version of the fetus can be performed, followed by extraction by the buttocks or feet.
What specific fetal injuries are possible during difficult extraction by the pelvic pole?
During difficult extraction of the fetus by the pelvic pole, a number of specific injuries associated with head entrapment or arm delivery are possible.
- Neck and spinal injuries — trauma to the neck muscles, vertebral arteries, cervical spine, and spinal cord during head entrapment.
- Arm fractures — a high risk of fractures occurs when releasing nuchal arms.
- Brachial plexus injury — occurs when the technique of the manual maneuver is violated. It includes upper Erb–Duchenne palsy (injury to the V–VI cervical segments) and lower Dejerine–Klumpke palsy (injury to the VII–VIII cervical and I–II thoracic segments).
By what maneuver is the aftercoming head delivered during fetal extraction by the pelvic pole?
Delivery of the aftercoming fetal head is performed using the classic manual maneuver — the Mauriceau–Smellie–Veit maneuver.
- Grasping the fetus — the child's torso is placed "straddling" the obstetrician's forearm.
- Flexion of the head: the index and middle fingers of the "lower" hand are placed on the fetal upper jaw. The middle finger of the "upper" hand presses on the occipital protuberance, while the remaining fingers lie on the shoulders.
- Traction: performed along the axis of the pelvic inlet/outlet: first posteriorly, then anteriorly.
To memorize the layers of the double-layer uterine suture: SM-SM (Mucosal-Muscular, then Serosal-Muscular). Suturing is performed from the inside out.
Class and exam questions
Does the uterine incision depend on the method of opening the abdominal wall?
There is no direct correlation. The uterine wall can be incised regardless of the lower midline abdominal incision. However, the typical combination is classical Cesarean section through a lower midline access, and lower segment incision through a Pfannenstiel or Joel-Cohen access.
Which specialists must be present during fetal extraction?
A mandatory condition is the presence of a neonatologist skilled in resuscitation techniques. In multiple pregnancies (twins), two neonatologists must be present during the surgery.
What are the specific features of uterine revision during an elective Cesarean section?
If the surgery is performed before the onset of labor, the surgeon must pass the index finger through the internal os of the uterine cervix to ensure drainage. After this action, changing gloves is mandatory.
What else to study on this topic
- Topography of anterior abdominal wall incisions (Pfannenstiel, Joel-Cohen, lower midline)
- Technique of isthmico-corporal Cesarean section and bladder mobilization
- Manual exploration of the uterine cavity: indications and technique
- Choice of suture material and peritonealization methods (third layer of sutures)
- Specifics of periotomy in adhesive disease and repeat laparotomy
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