Once the fascia is incised, the inferior fascial edge is grasped with Kocher clamps and elevated by an assistant as muscle either bluntly or sharply until the superior border of the symphysis pubis is reached. Next, the superior fascial edge is grasped and again, separation of fascia from the rectus muscle is completed. Blood vessels coursing between the sheath and muscles are clamped, cut, and ligated, or they are coagulated with an electrosurgery blade. Meticulous hemostasis is imperative to lower rates of incisional hematoma and infection. he fascial separation progresses cephalad and laterally to create a semicircular area above the transverse incision with a radius of approximately 8 cm. This will vary depending on fetal size. he rectus abdominis and pyramidalis muscles are then separated in the midline, irst superiorly and then inferiorly, by sharp and blunt dissection to expose the transversalis fascia and peritoneum.
he transversalis fascia and preperitoneal fat are bluntly dissected away to reach the underlying peritoneum. The peritoneum near the upper end of the incision is opened carefully, either bluntly or by elevating it with two hemostats placed approximately 2 cm apart. his upper site lowers cystotomy risks. The tented fold of peritoneum between the clamps is examined and palpated to ensure that omentum, bowel, or bladder is not adjacent. he peritoneum is then incised. The peritoneal incision is extended superiorly to the upper pole of the fascial dissection and downward to just above the peritoneal relection over the bladder. Importantly, in women with prior intraabdominal surgery, including cesarean delivery, omentum or bowel may be adhered to the undersurface of the peritoneum. In women with obstructed labor, the bladder may be pushed cephalad almost to the level of the umbilicus.
the operator separates the fascial sheath FIGURE 30-1 The loose peritoneum above the bladder reflection is grasped with forceps from the underlying rectus abdominis and incised with Metzenbaum scissors,
This incision begins 2 to 3 cm above the superior margin of the symphysis. It should suiciently long to allow fetal delivery, and 12 to 15 cm is typical. Sharp or electrosurgical blade dissection through the subcutaneous layers ultimately exposes the anterior rectus sheath. A small opening is made sharply with scalpel in the upper half of the linea alba. Placement here helps avoid potential cystotomy. Index and middle ingers are placed beneath the fascia to elevate it, and the fascial incision is extended irst superiorly and then inferiorly with scissors. Midline separation of the rectus muscles and pyramidalis muscles and peritoneal entry are similar to those with the Pfannenstiel incision.
Most often, the lower uterine segment is incised transversely as described by Kerr in 1921. Occasionally, vertical incision conined solely to the lower uterine segment may be elected (Kronig, 1912). In contrast, a classical incision begins as a low-vertical incision, which is then extended cephalad into the active portion of the uterine corpus. Last, a fundal or even posterior incision may be selected for cases with placental accrete syndromes.
For most cesarean deliveries, this incision is preferred. Compared with a classical incision, it is easier to repair, causes less incision-site bleeding, and promotes less bowel or omentum adherence to the myometrial incision. Located in the inactive segment, it also is less likely to rupture during a subsequent pregnancy.
Before any hysterotomy, the surgeon palpates the fundus to identiy degrees of uterine rotation. The uterus may be rotated so that one round ligament is more anterior and closer to the midline. In such cases, the uterus can be
FIGURE 30-2 This peritoneal edge is elevated and incised laterally.