What is the step-by-step procedure for a low transverse cesarean section, including surgical tools and medications such as cefazolin (antibiotic) and acetaminophen (pain management)?

Step-by-Step Guide to Low Transverse Cesarean Section

A low transverse cesarean section is the recommended surgical approach for most deliveries, utilizing a Pfannenstiel incision and transverse uterine incision to minimize maternal morbidity while optimizing neonatal outcomes. 1

Preoperative Preparation

Patient Positioning and Preparation

• Position patient supine with left lateral tilt (15-30 degrees) to prevent aortocaval compression
• Cleanse abdominal skin with chlorhexidine-alcohol solution
• Administer prophylactic antibiotics within 60 minutes before skin incision:
  • First-generation cephalosporin (cefazolin 2g IV) for all patients
  • Add azithromycin 500mg IV for women in labor or with ruptured membranes
• Consider vaginal preparation with povidone-iodine solution

Anesthesia

• Neuraxial anesthesia is preferred for elective cesarean sections:
  • Spinal anesthesia with intrathecal morphine 50-100 μg or diamorphine 300 μg
  • Alternatively, epidural morphine 2-3 mg or diamorphine 2-3 mg if using combined spinal-epidural technique
• Administer intravenous dexamethasone after delivery (absent contraindications) 2

Surgical Equipment

• Basic surgical tray including:
  • Scalpel with #10 blade for skin incision
  • Straight Mayo scissors for fascial incision
  • Curved Mayo scissors for extension of uterine incision
  • Metzenbaum scissors for dissection
  • Tissue forceps and pickups
  • Kocher clamps and hemostats
  • Retractors (Richardson, Deaver, or bladder retractor)
  • Needle holders
  • Suction device
• Suture materials:
  • Vicryl 0 or 1 for uterine closure
  • Vicryl 0 for fascial closure
  • Vicryl 2-0 or 3-0 for subcutaneous tissue
  • Monocryl 4-0 for subcuticular skin closure

Step-by-Step Surgical Procedure

1. Skin Incision

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

2. Fascial Entry

• Make a small midline incision in the fascia
• Extend fascial incision laterally using scissors
• Separate the rectus muscles vertically in the midline (do not cut)
• Develop the bladder flap by incising the peritoneum transversely

3. Uterine Entry

• Make a transverse incision in the lower uterine segment approximately 2 cm above the vesicouterine fold
• Extend the incision laterally using blunt finger dissection to reduce blood loss 1
• Ensure adequate width for atraumatic delivery

4. Delivery of Infant

• Insert hand into uterine cavity and elevate the fetal head
• Apply gentle fundal pressure to assist delivery
• Deliver the head, followed by shoulders and body
• Clamp and cut umbilical cord (consider delayed cord clamping for at least 30 seconds in preterm deliveries) 1
• Hand infant to pediatric team for assessment

5. Placental Delivery and Uterine Closure

• Allow spontaneous placental separation with gentle cord traction
• Administer oxytocin (10-40 units) in IV fluids after delivery
• Close the hysterotomy in two layers using continuous absorbable suture:
  • First layer through entire myometrium excluding decidua
  • Second layer to approximate serosal edges and achieve hemostasis 1

6. Abdominal Closure

• Irrigate the peritoneal cavity and check for hemostasis
• The peritoneum does not need to be closed (reduces operative time without affecting outcomes) 1
• Close the fascia with continuous delayed absorbable suture
• If subcutaneous tissue is ≥2 cm thick, reapproximate this layer
• Close skin with subcuticular suture for improved cosmesis and reduced wound separation 1

Postoperative Pain Management

Multimodal Analgesia Approach

• Continue regular paracetamol (1g IV/oral every 6 hours)
• Add NSAIDs (e.g., ibuprofen 600mg oral every 6 hours) after delivery
• Use opioids only for rescue analgesia
• If intrathecal morphine was not used, consider:
  • Local anesthetic wound infiltration
  • Transversus abdominis plane blocks
  • Quadratus lumborum blocks 2
• Consider transcutaneous electrical nerve stimulation as an analgesic adjunct

Potential Complications and Prevention

Immediate Complications

• Hemorrhage (4-6% risk with repeat cesarean sections)
• Infection (reduced with proper antibiotic prophylaxis)
• Bladder or bowel injury
• Venous thromboembolism (consider thromboprophylaxis with LMWH)

Long-term Complications

• Placenta accreta in future pregnancies (0.25-3% risk with multiple cesarean sections)
• Uterine rupture in subsequent pregnancies
• Adhesion formation
• Incisional hernia

Special Considerations

Difficult Cases

• For transverse lie or difficult fetal position, consider intra-abdominal version technique rather than resorting to classical incision 3
• For preterm deliveries, dense adhesions, or placenta previa/accreta where lower segment access is difficult, a vertical hysterotomy may be necessary, though this increases risks in future pregnancies 4

The Joel-Cohen surgical technique (modified Pfannenstiel approach with higher skin incision and blunt dissection) is associated with reduced operative time, blood loss, and postoperative pain 2, 1.

By following this standardized approach to low transverse cesarean section with careful attention to surgical technique and appropriate pain management, maternal morbidity can be minimized while optimizing neonatal outcomes.