FIGURE 30-9 Placenta bulging through the uterine incision as the uterus contracts. A hand gently massages the fundus to help aid spontaneous placental separation.
Traditionally, the peritoneum in the anterior cul-de-sac is approximated with a continuous 2-0 chromic catgut suture line. Multiple randomized trials suggest that omission of this step causes no postoperative complications (Grundsell, 1998; Irion, 1996; Nagele, 1996). If tubal sterilization is to be performed, it is completed as described in Chapter 39 (p. 702).
FIGURE 30-10 The cut edges of the uterine incision are approximated with a running, locking suture.
Following cesarean delivery, adhesions commonly form within the vesicouterine space or between the anterior abdominal wall and uterus. And, with each successive pregnancy, the percentage of afected women and adhesion severity rise (Morales, 2007; Tulandi, 2009). Adhesions can significantly lengthen incision-to-delivery time and total operative time (Rossouw, 2013; Sikirica, 2012). Although occurring infrequently, rates of cystotomy and bowel injury are also increased because of adhesive disease (Rahman, 2009; Silver, 2006).
Intuitively, scarring can be reduced by handling tissues delicately, achieving hemostasis, and minimizing tissue ischemia, infection, and foreign-body reaction. Most recent data on shortand long-term outcomes show no benefit to peritoneal closure (CAESAR Study Collaborative Group, 2010; CORONIS Collaborative Group, 2013, 2016; Kapustian, 2012). Similarly, most studies show no benefit from placement of an adhesion barrier at the hysterotomy site (Edwards, 2014; Kiefer, 2016).
Any laparotomy sponges are removed, and the paracolic gutters and cul-de-sac are gently suctioned of blood and amnionic fluid. Some surgeons irrigate the gutters and cul-de-sac, especially in the presence of infection or meconium. Routine irrigation in low-risk women, however, leads to greater intraoperative nausea but not to lower postoperative infection rates (Eke, 2016; Viney, 2012).
Prior to abdominal closure, correct sponge and instrument counts are verified. he rectus abdominis muscle bellies are allowed to fall into place. With significant diastasis, the rectus muscles may be approximated with one or two figure-of-eight sutures of 0 or no. 1 chromic gut suture. The overlying rectus fascia is closed by a continuous, nonlocking technique with a delayed-absorbable suture. In patients with a higher risk for infection, there may be theoretical value in selecting a monoilament suture here rather than braided material.
The subcutaneous tissue usually need not be closed if it is less than 2 em thick. With thicker layers, however, closure is recommended to minimize seroma and hematoma formation, which can lead to wound infection and/or disruption (Bohman, 1992; Chelmow, 2004). One recent metaanalysis found lower rates of seroma formation and of developing any wound complication with closure, but hematoma and wound infection rates were unafected (Pergialiotis, 2017). Addition of a subcutaneous drain does not prevent significant wound complications (Hellums, 2007; Ramsey, 2005).