What is the step-by-step procedure for a low transverse C-section (Cesarean section)?

Step-by-Step Procedure for a Low Transverse Cesarean Section

A low transverse cesarean section should be performed using a standardized technique with careful attention to anatomical layers, hemostasis, and gentle handling of tissues to minimize maternal morbidity and optimize neonatal outcomes. 1

Preoperative Preparation

1. Patient positioning:

   • Position patient supine with left lateral tilt (15-30 degrees) to prevent aortocaval compression
   • Arms should be extended on arm boards at <90 degrees

2. Skin preparation:

   • Cleanse abdominal skin with chlorhexidine-alcohol solution 2
   • Consider vaginal preparation with povidone-iodine solution 2

3. Antibiotic prophylaxis:

   • Administer first-generation cephalosporin IV within 60 minutes before skin incision
   • Add azithromycin for women in labor or with ruptured membranes 2

Surgical Procedure

Step 1: Abdominal Entry

1. Skin incision:

   • Make a Pfannenstiel (low transverse) skin incision approximately 2-3 cm above the symphysis pubis, extending 12-15 cm laterally 1
   • Incise through skin and subcutaneous tissue to the level of the fascia

2. Fascial entry:

   • Make a small midline incision in the fascia
   • Extend the fascial incision laterally using scissors
   • Separate the rectus muscles vertically in the midline (do not cut)

3. Peritoneal entry:

   • Carefully enter the peritoneal cavity
   • Identify and protect the bladder
   • Place a bladder retractor to keep the bladder away from the lower uterine segment

Step 2: Uterine Entry and Delivery

1. Uterine incision:

   • Make a transverse incision in the lower uterine segment approximately 2 cm above the vesicouterine fold
   • Blunt expansion of the uterine incision is recommended to reduce blood loss 1

2. Fetal delivery:

   • Insert hand into the uterine cavity and elevate the fetal head
   • Apply gentle pressure on the uterine fundus to assist delivery
   • Deliver the head, followed by shoulders and body
   • Clear the infant's airway if necessary (avoid routine suctioning) 1
   • Clamp and cut the umbilical cord (consider delayed cord clamping for at least 30 seconds in preterm deliveries) 1

Step 3: Placental Delivery and Uterine Closure

1. Placental delivery:

   • Allow spontaneous separation of the placenta
   • Apply gentle traction on the cord while providing counter-pressure on the uterus
   • Examine the placenta for completeness

2. Uterine closure:

   • Close the hysterotomy in two layers to potentially reduce the risk of uterine rupture in subsequent pregnancies 1
   • First layer: continuous locking suture through the full thickness of the myometrium
   • Second layer: continuous non-locking suture to imbricate the first layer

Step 4: Abdominal Closure

1. Peritoneal management:

   • The peritoneum does not need to be closed as this does not improve outcomes and increases operative time 1

2. Fascial closure:

   • Close the fascia with continuous delayed absorbable suture

3. Subcutaneous tissue closure:

   • If subcutaneous tissue is ≥2 cm thick, reapproximate this layer 1

4. Skin closure:

   • Close the skin with subcuticular suture, which is associated with reduced wound separation and improved patient satisfaction 1

Immediate Postoperative Care

1. Maternal monitoring:

   • Monitor vital signs, uterine tone, and vaginal bleeding
   • Provide multimodal analgesia including regional techniques and local anesthetic infiltration 2

2. Thromboprophylaxis:

   • Consider low-molecular-weight heparin, especially in cases with risk factors 2

3. Neonatal care:

   • Maintain newborn temperature between 36.5°C and 37.5°C 1
   • Ensure capacity for immediate neonatal resuscitation if needed 1
   • Avoid routine supplemental oxygen for the newborn 1

Special Considerations

1. In cases of cervical cancer: Consider a corporeal uterine incision to avoid surgical trauma to the lower uterine segment harboring cancer 2

2. For patients with portal hypertension: A median low abdominal skin incision may reduce hemorrhage risk compared to a low transverse incision 2

3. For preterm deliveries: The classical (vertical) uterine incision may be necessary if the lower segment is not well developed 3

Potential Complications

• Hemorrhage (4-6% risk with repeat cesarean sections) 1
• Infection (most common postoperative complication) 4
• Bladder or bowel injury
• Wound complications
• Venous thromboembolism
• Placenta accreta in future pregnancies (0.25-3% risk with multiple cesarean sections) 1

By following this standardized approach to low transverse cesarean section, surgical outcomes can be optimized while minimizing maternal and neonatal morbidity.