What are the steps involved in a low transverse cesarean section (c-section)?

Steps of a Low Transverse Cesarean Section

A low transverse cesarean section involves a series of specific surgical steps, beginning with appropriate skin preparation and ending with closure of all tissue layers. 1

Preoperative Preparation

• Anesthesia: Regional anesthesia (spinal or combined spinal-epidural) is preferred over general anesthesia due to rapid onset, simplicity, and reduced maternal risk 2
• Skin preparation: Chlorhexidine-alcohol solution for abdominal cleansing in the operating room 1
• Antibiotic prophylaxis: Administer intravenous antibiotics within 60 minutes before skin incision (first-generation cephalosporin with azithromycin for women in labor or with ruptured membranes) 1
• Consider vaginal preparation with povidone-iodine solution to reduce infection risk 1

Surgical Procedure

1. Skin incision

   • Pfannenstiel (slightly curved) or Joel-Cohen (straight) transverse incision about 2-3 cm above the pubic symphysis 3
   • The Joel-Cohen/modified Misgav-Ladach technique is associated with less post-surgical acute and chronic pain 3

2. Subcutaneous tissue dissection

   • Blunt and sharp dissection through subcutaneous fat to the level of the anterior rectus sheath

3. Fascial incision

   • Transverse incision of the anterior rectus fascia
   • Extend laterally using scissors or fingers

4. Rectus muscle separation

   • Separate the rectus muscles vertically in the midline
   • Blunt dissection to expose the peritoneum

5. Peritoneal entry

   • Open the peritoneum carefully to enter the abdominal cavity
   • Extend the opening to provide adequate exposure

6. Bladder flap creation

   • Identify the vesicouterine fold of peritoneum
   • Create and dissect a bladder flap to mobilize the bladder downward away from the lower uterine segment

7. Uterine incision

   • Make a transverse incision in the lower uterine segment
   • Extend laterally with fingers or scissors to create adequate width for delivery

8. Delivery of the fetus

   • Insert hand into the uterine cavity
   • Elevate the fetal head through the incision
   • Deliver the body and complete extraction of the fetus

9. Cord clamping and placental delivery

   • Clamp and cut the umbilical cord
   • Allow or assist placental delivery with controlled cord traction
   • Examine placenta for completeness

10. Uterine closure

    • Clean the uterine cavity of debris and blood clots
    • Close the uterus in one or two layers with continuous absorbable suture

11. Peritoneal closure

    • Optional closure of the visceral peritoneum over the uterine incision
    • Optional closure of the parietal peritoneum

12. Fascial closure

    • Close the rectus fascia with continuous or interrupted absorbable sutures

13. Subcutaneous tissue and skin closure

    • Close subcutaneous tissue if >2 cm thick
    • Close skin with subcuticular suture or staples

Special Considerations

• For patients with portal hypertension with abdominal wall variceal vessels, a median low abdominal skin incision may afford lower risks of hemorrhage than a low transverse skin incision 4

• For patients with gynecologic cancers, particularly cervical cancer, a corporeal uterine incision is recommended to avoid surgical trauma of the lower uterine part harboring the cancer 4

• Pain management: Multimodal analgesia including regional analgesia techniques and infiltration with local anesthetics is recommended 4

• Thromboprophylaxis: Consider low-molecular-weight heparin, especially in postoperative setting or in case of immobilization 4

Postoperative Care

• Monitor for signs of bleeding, infection, or other complications
• Provide adequate pain control through multimodal analgesia
• Early mobilization to reduce risk of thromboembolism
• Remove urinary catheter within 24 hours if no complications

The low transverse cesarean technique has evolved significantly over the past century, with improvements in surgical approach leading to better maternal outcomes and reduced complications 5.