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Published online: 2020-02-06
THIEME
S98 Precision Surgery in Obstetrics and Gynecology
Classical Cesarean Section
1
AmanoKan,MD,PhD
1Department of Obstetrics and Gynecology, Center for Perinatal Address for correspondence Amano Kan, MD, PhD, Department of
Medicine,KitasatoUniversitySchoolofMedicine,YoshidaObstetrics Obstetrics and Gynecology, Center for Perinatal Medicine, Kitasato
and Gynecology Clinic, Tokyo, Japan University School of Medicine, Yoshida Obstetrics and Gynecology
Clinic, 251-0861 5061-4 Ohba Fujisawa-City, Kanagawa, Japan
Surg J 2020;6(suppl S2):S98–S103. (e-mail: kanamano0101@gmail.com).
Abstract Cesarean section is the most common surgery in obstetrics. Several techniques are
proposed according to the indication and the degree of urgency. Usually laparotomy
followedbyhysterotomywithalowtransverseincisionispreferable.However,incases
inwhichitisdifficulttoaccesstheloweruterinesegment,suchasthatinpretermlabor,
Keywords dense adhesion, placenta previa/accrete a vertical hysterotomy (classical cesarean
► cesarean section section)maybeneeded.Althoughasmoothandgentledeliveryofthefetusispossible
► vertical uterine through the vertical incision, uterine closure is technically difficult. To decrease the
incision risks of hemorrhage and adhesion, a speedy and skillful technique is mandatory. The
► classical cesarean mostserious risk of vertical incision in the contractile corpus is uterine rupture in the
section subsequentpregnancy.Therefore,cases of prior classical cesarean section are contra-
► uterine rupture indicated for trial of labor after cesarean section.
Cesareansectionisthemostfrequentobstetricoperationthatis Indications for Classical Cesarean Section
performedincaseswhenavaginaldeliverywouldputthefetus Preterm Labor
ormotheratrisk.Severalproceduresareoffereddependingon Since the poorly developed lower uterine segment provides
theindicationandthedegreeofurgency.Afterlaparotomy,the inadequate space for the manipulations required for fetal
uterus can be incised by a variety of techniques, usually low delivery, especially in cases prior to 30 weeks of gestation,
transverseuterineincisionisselected(►Fig.1).Attimes,alow with nonreassuring fetal status or inevitable preterm labor
transverse hysterotomy is selected but provides inadequate arecandidatesfortheclassicalcesareansection.Ininstances
roomfordelivery. Insuch cases incision is extended such as J- when the fetus is very small, especially in case of a breech
extension, U-extension, and T-extension. However, in some presentation,thesmallfetalheadmaybecomeentrappedby
cases, where the low transverse incision is arduous, a midline the small low transverse incision space and uterine contrac-
vertical incision (classical cesarean section) is considered. tions, therefore classical cesarean section is desirable to
prevent the fetal risk of intracranial hemorrhage. The risks
Surgical Steps of neonatal mortality and morbidity may be decreased by
classical cesarean section in some cases of preterm labor
(►Table 1).
1. Midline vertical incision for laparotomy
↓ Fetal Indications
2. Hysterotomybymidlinevertical incision abovethe Transverselieofalargefetus,especiallyifthemembranesare
lower segment ruptured and the shoulder is impacted in the birth canal
↓ necessitates a classical incision. A fetus presenting as a back-
3. Delivery of the fetus/placenta downtransverselieisparticularlydifficulttodeliverthrough
↓ a low transverse incision.
4. Uterine repair Malformedfetussuchasconjoinedtwins,sacrococcygeal
↓ teratoma, macrocrania, myelomeningocele is difficult to
5. Abdominal closure deliver gently through a low transverse incision.
DOI https://doi.org/ Copyright © 2020 by Thieme Medical
10.1055/s-0039-3402072. Publishers, Inc., 333 Seventh Avenue,
ISSN 2378-5128. NewYork, NY 10001, USA.
Tel: +1(212) 760-0888.
Classical Cesarean Section Kan S99
Fig. 1 Variety of incisions for hysterotomy. (A) Low transverse. (B)Lowvertical.(C) Low transverse with T-extension in the midline. (D)Low
transverse with J-extension. (E) Low transverse with U-extension. (F)Hightransverse.(G)Fundaltransverse.(H) Midline vertical (classical
incision). (Reproduced with permission of Amano K. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical
Procedures OGS NOW, No.3. Cesarean Section. (Japanese). Tokyo: Medical View; 2010:42–47. Copyright © Medical View).
Table 1 Indications for classic cesarean section Placenta Previa
Preterm labor Breech, transverse lie Incaseofplacentaprevia,placentalincisionshouldbeavoided,
(30 wk) especially if the placenta accrete is suspected from prenatal
Nonreassuring fetal status ultrasonographyandintraoperativeinspectionoftheengorged
Difficult to Serious adhesion around the uterine superficial vessels, a classical incision or a fundal
access the vesicouterine space transverse incision is advisable. If placenta accrete/increta is
lower segment Morbidobesity suspected,auterineincisionisperformedwhilekeepingaway
Uterine Myomauteri from the placenta and after delivering the fetus, the cord is
abnormality Anomalousuteri ligated and cut, and the placenta is left in situ. The uterine
incisionissuturedbyacontinuousrunninglockingsuture,and
Cervical carcinoma a hysterectomy is immediately performed.
Fetal indication Malformation (macrocrania,
sacrococcygeal teratoma, Procedure of the Classical Cesarean Section
myelomeningocele, conjoined twins)
Transverse lie Abdominal Incision
Usually a midline vertical incision is chosen for laparotomy.
A vertical infraumbilical incision provides quick entry to
Uterine Abnormality shorten the incision-to-delivery interval. Moreover, this inci-
In cases of an anomalous uterus with a hypoplastic cervix, sion has minimal blood loss, provides superior access to the
myoma uteri, or invasive cervical cancer a low transverse upper abdomen and generous operating room, and offers
incision is not indicated. flexibility for easy wound extension if greater space or access
isneeded.Themaindisadvantagesarepoorercosmeticresults,
Difficult Access to the Uterine Lower higher rates of fascial dehiscence or incisional hernia, and
Segment greater postoperative pain compared with a Pfannenstiel
transverse incision.
Whenitisveryhardtoaccesstheuterinelowersegment in An infraumbilical midline vertical incision begins 2 to
cases with dense adhesion, or morbid obesity, incision into 3cmabovethesuperiormarginofthesymphysisandshould
the vesicouterine peritoneum and separating the bladder is be of sufficient length (12–14cm) to allow fetal delivery
difficult, indicating a classical cesarean section. without difficulty. Sharp or electrosurgical dissection is
The Surgery Journal Vol. 6 Suppl. S2/2020
S100 Classical Cesarean Section Kan
performed to the anterior rectus sheath. Fascial incision is
extended superiorly and inferiorly with scissors or scalpel.
The rectus abdominis and pyramidalis muscles are subse-
quently separated, and the peritoneum is carefully opened.
Before hysterotomy, the surgeon should palpate the fundus
and adnexa to identify the degree of uterine rotation. The
uterus may be dextrorotated due to the proximity of the
sigmoid colon so that the left round ligament is more
anterior and closer to the midline.
Uterine Incision
Amidlinevertical uterine incision in the contractile corpus is
carefully initiated with a scalpel until the membranes
appeared, and when the uterus is entered, the incision site is
openedwithfingerswideenoughtomakeanadequatespaceto
deliver the fetus. If the placenta is encountered in the incision
line, the placenta is torn off and membranes are ruptured as
quickly as possible to avoid severe fetal hemorrhage. As the
incisionisopened,numerouslargevesselsthatbleedprofusely
are commonlyencounteredwithinthemyometrium.
Aspeedyandskillful technique is mandatory. Fig. 2 Closure of the firstlayer.TextA:Closingthefirst layer by
Alowvertical incision is made parallel to the longitudinal intermittentsuturesincludesthedeepmyometrialedgewithminimal
decidua. (Reproduced with permission of Amano K. In: Hiramatsu Y,
axis of the uterus in the midline with carebeing taken to stay KonishiI,SakuragiN,TakedaS,eds.MasteringtheEssentialSurgical
belowthecontractileportionoftheuterusandwithinthethin Procedures OGS NOW, No.3. Cesarean Section. (Japanese). Tokyo:
lower uterine segment. Studies have shown that there is no Medical View; 2010:42–47. Copyright © Medical View).
significant increased risk of uterine rupture in patients with
this type of incision compared with low transverse incision.
Delivery of the Fetus and Placenta The main principle to remember is that the dead space
After the membranes are ruptured, the fetus will be deliv- needs to be obliterated to achieve hemostasis and it
ered easily compared with cases with a low transverse reduces the chance of hematoma formation. The first layer
incision.Theumbilicalcordshouldbeligatedandcut.Fundal is closed with interrupted sutures (#1 Coated VICRIL PLUS,
massagemaybeginassoonasthefetusisdeliveredtohasten ETICON Inc.) with decidual exclusion to avoid endometrial
placental separation, and the placenta is manually removed. inversion at the scar site, because this may be the cause of
Immediatelyafterdeliveryoftheplacenta,theuterinecavity incomplete scar healing (►Fig. 2). Concerns have been
is suctioned and wiped out with a gauze sponge to remove expressed that sutures through the decidua may lead to
the remaining membranes, vernix, and clots. endometriosis or adenomyosis in the hysterotomy scar,
After birth, to facilitate the uterine contraction, an intra- however, this is rare. The second layer is also closed with
venous infusion of 10 units oxytocin in 1L of crystalloid interrupted sutures, and the final layer is closed with
solution may be begun. Second-line agents are ergot alka- continuous locking sutures or figure-of-eight sutures
loids, and the use of tranexamic acid has recently been (►Figs. 3, 4).
described to lower blood loss during cesarean delivery. After closure of the incision, an adhesion barrier patch,
There is insufficient evidence of mechanical or finger such as SEPRAFILM, KAKEN Inc. or GYNECARE INTERCEED,
dilatation of the cervix during nonlabor cesarean section ETICHON Inc. is applied.
to reduce postoperative morbidity such as infection rates
from potential hematometra. AbdominalClosure
Prior toabdominalclosure,allsurgicalspongesareremoved,
Uterine Repair andtheparacolicguttersandcul-de-sacaregentlysuctioned
of blood and amniotic fluid. The uterine contraction, hemo-
Afterremovaloftheplacenta,theuterusisliftedthroughthe stasis of the incision, and the aspect of the adnexa are then
incision onto the abdominal wall. Although some clinicians confirmed. After gauze and instrument counts are found to
prefer to avoid such exteriorization, there are often benefits be correct, the abdominal cavity is irrigated with warmed
that outweigh the disadvantages. saline.
For incision closure, it is helpful to have an assistant Abdominal incisions are closed in layers. Peritoneum
compress the uterus on each side of the wound toward the fasciaisclosedwithinterruptedsutureorcontinuoussuture,
midlineaseachstichisplacedtoachievegoodapproximation. and subcutaneous tissue is approximated with interrupted
Because the classical incisions are much thicker, they are suture.Skinisclosedwithstaplersand/orinterruptedrelax-
normally repaired in three layers. ation sutures.
The Surgery Journal Vol. 6 Suppl. S2/2020
Classical Cesarean Section Kan S101
Table 2 Merits and demerits for classical cesarean section
Merits Deliver the fetus without difficulty
Avoid bladder injury
Extend incision without lacerating uterine arteries
Demerits Increased blood loss
Difficulty of uterine closure
Increased complications of infection
Postoperative adhesion
Subsequent uterine rupture or uterine scar
dehiscence
(low vertical; n¼53, classical; n¼134) versus low trans-
verse incision in preterm cesarean section between 23 and
34weeksofgestation.Afteradjustingforconfounders,there
was no significant difference in the incision-to-delivery
interval between the two types of incisions. However, the
Fig.3 Closureofthesecondlayer.TextB:Thesecondlayercompletesthe risk for maternal transfusionwashigheramongthosewitha
myometrial approximation and hemostasis. The dead space needs to be vertical incision. The incision type was not associated with
obliterated. (Reproduced with permission of Amano K. In: Hiramatsu Y, any neonatal outcomes including intracranial hemorrhage,
Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical low Apgar score, or neonatal mortality. The need for rapid
ProceduresOGSNOW,No.3.CesareanSection.(Japanese).Tokyo:Medical delivery is not justified by Luthra et als’ findings, and this
View; 2010:42–47. Copyright © Medical View).
shouldnolongerbeconsideredasanindicationforavertical
Benefits and Risk of Classical Incision incisioninthepretermpopulation.Furtherstudiesincluding
the effect on long-term outcome are warranted (►Table 2).
Benefits
Thefetus can be delivered quickly and gently with minimal Risks
risk of forcing delivery which may result in intracranial
hemorrhage in a preterm case. Intraoperative, Postoperative Risk
1
Luthra et al compared the uterine incision-to-delivery Asaclassical uterine incision is made by incising the uterus
intervalandneonatalandmaternalcomplicationsinvertical parallel to the longitudinal axis of the uterus through the
Fig. 4 Closure of the third layer. (A)Zsuture.(B) Continuous suture, figure-of-eight suture. (Reproduced with permission of Amano K. In:
Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean Section. (Japanese).
Tokyo: Medical View; 2010:42–47. Copyright © Medical View).
The Surgery Journal Vol. 6 Suppl. S2/2020
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