Main surgical approaches and uterine incisions
The choice of access is determined by the clinical picture. The most common option is a transverse suprapubic incision (according to Pfannenstiel or Joel-Cohen) with incision of the lower uterine segment. It provides a good cosmetic result, rarely results in hernias, and allows the patient to get up early.
- Classical cesarean section: a longitudinal incision is made, and the uterus is sutured with a continuous double-layer suture.
- In the lower segment: after opening the vesicouterine fold (plica vesicouterina) and separation of the urinary bladder, a small transverse incision is made. According to the Gusakov method, it is extended bluntly (with fingers) to 10–12 cm. If delivery of the head is difficult, a scissors incision upward according to Dörfler or an "anchor incision" (inverted T-shape) is performed.
- Fundal hysterotomy: used for placenta accreta in the scar area, severe adhesions, or multiple myomas. The incision is made on the anterior wall as close to the fundus as possible.
Extraction of the fetus and management of the third stage of labor
The extraction technique depends on the presentation:
- In cephalic presentation, the surgeon inserts the left hand into the uterus, flexes the head, and delivers it by the occiput into the wound while the assistant pushes on the fundus of the uterus. If difficulties arise, a blade of obstetric forceps is guided under the lower pole of the head.
- In breech presentation, the fetus is extracted by the inguinal crease or foot.
- In transverse lie, traction is applied by the foot, and the head is delivered using the Mauriceau-Smellie-Veit maneuver.
After clamping and cutting the umbilical cord, a broad-spectrum antibiotic and oxytocin (IU 5) are administered intravenously to prevent hemorrhage. The placenta is removed by cord traction. A critically important step is manual revision of the uterine walls to rule out retained placental tissue and pathologies, as well as digital verification of cervical canal patency (after which the surgeon must change gloves).
Wound closure and the Stark method
The classical technique involves closing the uterus with two rows of interrupted sutures and mandatory reperitonealization using the vesicouterine fold. The anterior abdominal wall is repaired strictly in layers.
A modern alternative is the Stark method. Its key differences are:
- Joel-Cohen laparotomy (superficial straight-line incision).
- The peritoneum is opened digitally to minimize the risk of bladder injury.
- The vesicouterine fold is not opened beforehand.
- The uterine incision is closed with a single-layer continuous locking suture according to Reverdən.
- Avoidance of reperitonealization: the peritoneum and muscles are not sutured, which significantly speeds up the operation.
Complications and the postoperative period
Complications (hematomas, bleeding, trauma to adjacent organs, purulent-septic processes) are more often associated with the patient's severe morbid background than with the surgical technique itself. In elective interventions, the risk of complications is 2–3 times lower than in emergency cases.
In the early postoperative period:
- With regional anesthesia, the baby is placed on the mother's chest right in the operating room for 5–10 minutes.
- Infusion therapy is prescribed (preferably crystalloids), along with antispasmodics and uterotonics.
- To prevent intestinal paresis, prokinetics and anticholinesterase drugs are used by the end of the first 24 hours, followed by a cleansing enema.
- Discharge for an uncomplicated course is possible on days 3–5.
Obstetric forceps as an alternative
In modern obstetrics, the frequency of use of obstetric forceps (forceps obstetrician) has sharply decreased in favor of cesarean section due to the high risk of trauma. Forceps (e.g., the Simpson-Phenomenov model) are exclusively a traction instrument, not a rotational one.
Their application is permitted only by an experienced physician and strictly when the fetal head has engaged with its large circumference in the narrow cavity of the lesser pelvis. If the head is at a high station or if it is necessary to eliminate maternal pushing efforts (severe preeclampsia, high-grade myopia), the application of forceps is contraindicated—in such cases, a cesarean section is performed.
Briefly: answers to topical questions
What are the indications and contraindications for the application of obstetric forceps?
The indication for applying obstetric forceps (forceps obstetrician) is the need to urgently terminate the second stage of labor.
Contraindications to the application of obstetric forceps:
- dead fetus;
- incomplete cervical dilation;
- fetal hydrocephalus, anencephaly;
- premature fetus;
- high station of the fetal head: the head is engaged, located with its largest diameter at the pelvic inlet or in the wide part of the pelvic cavity;
- threatened or impending uterine rupture.
Triple rule for applying obstetric forceps: The Left blade is taken with the Left hand, and is introduced into the Left half of the pelvis (and always first!).
Class and exam questions
Why should one be careful with the urinary bladder during the Pfannenstiel approach?
At the end of pregnancy and especially during labor, the upper border of the urinary bladder rises 5–6 cm above the pubic bone, so when dissecting tissues, there is a high risk of its accidental injury.
What is the essence of widening the uterine incision according to Gusakov?
After a small starting transverse incision with a scalpel, the surgeon widens the wound bluntly using the index fingers of both hands up to 10–12 cm. This is done to avoid causing a scalp laceration to the fetal head.
Why is manual revision of the uterine cavity necessary after placental delivery?
This is a mandatory step to rule out retained placental lobules and fetal membranes, as well as to identify submucosal myoma nodes or intrauterine septa.
When can anticoagulants be prescribed after a Caesarean section?
To minimize the risk of postoperative bleeding, anticoagulants are administered strictly no earlier than 8–12 hours after the completion of surgery.
What else to study on this topic
- Surgical tactics for placenta accreta (excising the altered myometrium)
- Technique of performing the Dörfler incision and the "anchor" incision on the uterus
- Design and curvature system of Simpson-Phenomenov obstetric forceps
- Indications for cavity, typical, and outlet obstetric forceps
- Prevention and medical treatment of postoperative intestinal paresis
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