The anterior surface of the uterus is opened longitudinally along its midline. This is best accomplished by making an incision a few centimetres long with a scalpel, and then rapidly enlarging it with the scissors to 16 or 18 centimetres. The membranes are then ruptured, the child is seized by one foot and rapidly extracted.
—J. Whitridge Williams (1903)
From the above description, cesarean technique has evolved during the past century. For example, preference for classical hysterotomy has given way to low transverse incision. Evidence-based data now guide many surgical steps and are presented throughout this chapter.
Of definitions, cesarean delivery defines the birth of a fetus via laparotomy and then hysterotomy. This definition is not applied to removal of the fetus from the abdominal cavity in the case of uterine rupture or with abdominal pregnancy. Rarely, hysterotomy is performed in a woman who has just died or in whom death is expected soon—postmortem or perimortem cesarean delivery (Chap. 47, Cardiopulmonary Resuscitation).
In some instances, abdominal hysterectomy is indicated following delivery. When performed at the time of cesarean delivery, the operation is termed cesarean hysterectomy. If done within a short time after vaginal delivery, it is termed postpartum hysterectomy. Peripartum hysterectomy is a broader term that combines these two. In most cases, hysterectomy is total, but supracervical hysterectomy is an option. The adnexa are not usually removed. In most instances, a simple or type I hysterectomy is performed. However, for women with invasive cervical cancer, radical hysterectomy removes the uterus, parametrium, and proximal vagina to achieve tumor excision with negative margins. Also, for cases of placenta percreta that extend toward the pelvic sidewall, similar radical excision of the parametrium may be needed.
CESAREAN DELIVERY IN THE UNITED STATES
In the United States, the cesarean delivery rate rose from 4.5 percent in 1970 to 32.9 percent in 2009. Following this peak, the rate has trended slightly downward, and it was 32.0 percent in 2015 (Martin, 2017). Some indications for performing cesarean delivery are shown in Table 30-1. More than 85 percent of these operations are performed for four reasons—prior cesarean delivery, dystocia, fetal jeopardy, or abnormal fetal presentation. The latter three compose the main indications for primary cesarean delivery (Barber, 2011; Boyle, 2013).
TABLE 30-1Some Indications for Cesarean Delivery |Favorite Table|Download (.pdf) TABLE 30-1 Some Indications for Cesarean Delivery
|Prior cesarean delivery |
|Abnormal placentation |
|Maternal request |
|Prior classical hysterotomy |
|Unknown uterine scar type |
|Uterine incision dehiscence |
|Prior full-thickness myomectomy |
|Genital tract obstructive mass |
|Invasive cervical cancer |
|Prior trachelectomy |
|Permanent cerclage |
|Prior pelvic reconstructive surgery |
|Prior significant perineal trauma |
|Pelvic deformity |
|HSV or HIV infection |
|Cardiac or pulmonary disease |
|Cerebral aneurysm or arteriovenous malformation |
|Pathology requiring concurrent intraabdominal surgery |
|Perimortem cesarean delivery |