*5.4.1 Transverse uterine incision*

This is the incision recommended for most patients unless there is a contraindication. For the term pregnancies the incision is made 2-3 cm below the upper edge of the uterovesical fold of the peritoneum [12, 13].

*Caesarean Section DOI: http://dx.doi.org/10.5772/intechopen.97290*

Advantages of lower segment incision:


There are different types of incisions on the uterus to deliver the fetus [14], but Kerr incision is the one performed commonly in uncomplicated cases.


If there is a need to extend the incision this should be done with blunt dissection as sharply extending the uterine incision significantly increases intraoperative blood loss and the need for blood transfusion [12].

The incision to delivery intervals does not significantly contribute to Apgar scores and cord blood gases, but the maternal status prior to caesarean section and optimal anaesthetic management are the most important factors for good neonatal outcome [13, 15].

Lower vertical uterine incision are of 2 types which is either on the lower segment or on the upper segment. The lower segment vertical incision is as strong as the lower segment transverse incision. The major disadvantage of the low vertical incision is likelihood of extension cephalad into the uterine fundus or caudally into the bladder, cervix or vagina.

The classical incision is rarely performed at or near term because of its likelihood to rupture spontaneously antenatally or early in labour. It also associated with increased maternal morbidity [16] (**Figures 5**–**8**).

Indications for vertical uterine incision are [17]:


**Figure 5.** *Different types of uterine incisions.*

**Figure 7.** *Second layer closure technique.*

**Figure 8.** *Abdominal closure techniques.*


#### **5.5 Extraction of the fetus**

The fetus should be extracted expeditiously and in a non-traumatic way. The delay in delivery after a uterine incision with contractions following leads to decreased uteroplacental blood flow and compromise the fetus [15]. Fingers are put around the curvature of the fetal head for leverage, lifting without overly flexing the wrist not using the lower segment and symphysis pubis as a fulcrum, to avoid extensions of the incision. The head is gently elevated and flexed to bring the occiput into incision, with the aid of modest fundal pressure. The shoulders are then delivered transversely along the largest diameter of the incision. Of note that there are conditions that may make this process difficult like impacted head and abnormal lie [16, 17]. Instrumental delivery has been suggested to assist delivery of the fetal head when is found to be difficult and forceps are preferred. The objective should be to carry out an atraumatic fetal delivery as possible.

#### **5.6 Cord clamping**

For newborns who do not require resuscitation delayed cord clamping for 30-60 seconds is recommended. Clamping should be done following onset of respiration.

Delivery of the placenta should be by cord traction as this has many benefits compared to manual removal and the use of oxytocin [18].

Advantages are:

1.Less blood loss

2.Less endometritis


#### **5.7 Closure of uterine incision**

After the delivery of the placenta is exteriorized onto the abdominal wall although this kinks the uterine vessels and may seem like there is no bleeding which may occur when replaced back in the pelvis. It is therefore advisable that when replaced haemostasis is verified by checking with systolic blood pressure of 100 mmHg or more. Non exteriorization is challenging but reassures for the achievement of haemostasis. The benefits of exteriorization found was only shorter surgical time [19, 20].

Uterine incision closure technique is the most important factor for good healing to minimise complications later. The assistant should compress the uterus to assist in approximation of the wound edges. Dead spaces need to be obliterated to achieve haemostasis. The angles of the incision should be secured and a full thickness needle bite 1 cm away from the margin of the incision and coming out at the junction of the

#### *Caesarean Section DOI: http://dx.doi.org/10.5772/intechopen.97290*

myometrium and decidua using polyglactin, poliglecaprone or catgut 1 sutures to avoid endometrial inversion at the scar site as this may delay healing. The type of a suture is largely based on personal preference with no statistical difference in maternal outcome [21, 22]. Double uterine incision closure with continuous locked or unlocked suture [23]. Two layer rather than a single layer is preferred but in a patient performing tubal ligation single layer can be done as there is no concern of subsequent uterine rupture.

Closure of the classical incision has no consensus as interrupted or continuous sutures have been used but the important objective is to obliterate all dead spaces. Approximation of the edges is important to minimise the tension when sutures are placed. The thick myometrium should have a separate layer of suture.

Abdominal irrigation with the use of prophylactic antibiotics seems not to reduce the maternal morbidity but also has not been found to be harmful.

Peritoneal closure has been found to be associated with adhesion formation, but personal experience is different. This may be due to marked tissue handling rather than washing. Re-operating on the patients self-operated before can clarify this issue. The lesser the tissue handling the lesser the adhesion formation.

There is no need for rectus muscle re-approximation unless in cases if rectus diasthesis to minimise visceral injury in subsequent abdominal surgical procedures. It is recommended that subcutaneous tissue with a depth of 2 cm or more should be closed to obliterate dead spaces using interrupted suture.

Skin closure can done with fine sutures like rapidly absorbable continuous or interrupted sutures unless in septic cases where interrupted non absorbable suture closure is mandatory. Absorbable suture give the best aesthetic outcome especially post caesarean section [24].

The challenge for performing caesarean section is when there is prolonged rupture of membranes as this may be associated with severe infections. Before the era of effective antibiotics extra-peritoneal caesarean section was advised. The skill to perform such a procedure has disappeared as effective antibiotics became available. Though the procedure had advantages like less postoperative pyrexia, less hospital stay, less incidence of pelvic abscesses and septic shock, less wound sepsis, lower incidence of secondary post-partum haemorrhage and need for further surgery, it had a prolonged anaesthetic time to delivery [25]. This was a way of minimising complications associated with caesarean section in the presence of infection.
