Welcome back to the second part of my Cesarean Section Basics series! If you haven’t already listened to Part 1, I highly recommend checking it out, as it covers everything that needs to happen before the first incision is made. In today’s episode, I’m walking through each surgical step of a cesarean delivery, all the way up to the hysterotomy.

As an intern, I wasn’t allowed to scrub in as the primary surgeon unless I could verbally recite every step of the procedure to my senior or attending. I spent a significant portion of my intern year reading and re-reading procedural steps and op notes, and I imagine many of you will soon be in a similar position. This episode is meant to help you prepare for that!

I also have a free resource for you—a copy of my own C-section op note template. I found that reading op notes helped me better visualize procedures, often more effectively than textbooks.

Key Resources for Surgical Techniques

The information in this episode is drawn from four primary resources:

ACOG Surgical Curriculum, Cesarean Delivery Module – A fantastic resource I highly recommend.
Gabbe’s Obstetrics Textbook (Cesarean Delivery Chapter)
Evidence-Based Surgery for Cesarean Delivery: An Updated Systematic Review– Analyzing evidence-based techniques from 73 randomized controlled trials and multiple systematic reviews (published in 2013).
The Case For Standardizing Cesarean Delivery Technique – Reviewing 216 additional studies and reinforcing previously recommended standardizations (published in 2020).

When I reference “evidence suggests” or “evidence supports,” I’m referring to these last two sources, which I’ve linked in the show notes.

Step-by-Step Cesarean Procedure

1. Skin Incision

There are four main skin incision types:

Pfannenstiel: Slightly curved, 2-3 cm above the pubic symphysis (most common for routine cases).
Midline Vertical: Extends upwards towards the umbilicus, starting 2-3 cm above the pubic symphysis.
Joel Cohen: A straight, transverse incision, about 3 cm caudad to the imaginary line joining the anterior superior iliac spines (ASIS)
Maylard: A curved incision, 5-8 cm cephalad to the pubic symphysis.

Incisional technique can be kind of confusing. All 4 of those incision types that I mentioned are skin incisions, but they also represent different methods of dissection that occur internally. For example, you can make a Pfannenstiel skin incision, but dissect the fascia and enter the peritoneum in a Joel Cohen fashion. Or, you can make a Joel Cohen skin incision, but transect the rectus in a Maylard fashion. I will link to a great chart provided in the show notes from CREOGs Over Coffee (a fantastic podcast if you haven’t already heard of it) that breaks down all the different styles of dissection.

The type of incision depends on urgency, prior surgical history, and the need for additional abdominal exploration. Skin incisions can be made using a scalpel or Bovie electrocautery (less commonly used). The incision length should be about 15 cm for a term fetus.

2. Subcutaneous Tissue & Fascia

Subcutaneous Tissue: Sharp entry (scalpel or Bovie) but blunt dissection is recommended. Stay in the midline to avoid transecting the superficial epigastric arteries.
Fascial Entry: Small midline incision (~3 cm), followed by lateral stretching in a curvilinear motion to prevent inadvertent muscle injury.
Scarred Cases: If previous surgery has caused significant scarring, sharp dissection using Mayo scissors or Bovie may be necessary.

3. Rectus Muscle & Peritoneal Entry

Rectus Muscle Separation: Muscles are stretched laterally rather than cut.
Peritoneal Entry: Preferred technique is blunt entry using an index finger. If scarring is present, Kelly clamps can be used to tent the peritoneum, which is then incised with Metzenbaum scissors.
Bladder Flap Omission: Evidence suggests omitting the bladder flap to reduce operative time and short/long term bladder symptoms given that it has not been shown to reduce rates of bladder injury.

4. Uterine Incision (Hysterotomy)

There are five main types of uterine incisions:

Low Transverse (most common & preferred) – Less blood loss and allows for future TOLAC/VBAC.
Low Vertical – Involves mostly the LUS but can be extended into a classical incision.
Classical – Entirely within the upper uterine segment.
J-Incision – Extension of a transverse incision in a J-shape to the upper uterine segment and parallel to the ascending branch of the uterine artery.
T-Incision – Midline extension of a transverse incision.

Potential indications for vertical incisions:

Poorly developed LUS (gestational age <25wks)
Back down, transverse fetal lie
Anterior obstructing fibroid
Complete anterior previa
Fetal anomalies necessitating more space to enable delivery

To minimize unintended extensions and blood loss, evidence supports creating a small (2-3 cm) transverse incision in the lower uterine segment, then entering the cavity bluntly with a finger. The incision is then extended cephalocaudad (toward the head and feet) rather than laterally to prevent bleeding.

Once the uterine incision is made, the membranes can be ruptured, and the fetus delivered.

Conclusion

That brings us to the end of today’s episode! In Part 3, we’ll discuss fetal delivery and abdominal closure. Be sure to check the show notes for all the resources mentioned, including my free C-section op note template. See you next week!

Cesarean Delivery Basics: Surgical Steps (From Skin Incision to Hysterotomy)