Clinical overview
Caesarean section (CS) is the most commonly performed major operation in South African obstetrics and, in many district and regional hospitals, the single highest-volume theatre procedure. As a registrar you will do hundreds, frequently at night, often as the most senior obstetric hand in the building, and sometimes on a woman who is bleeding, septic, or whose fetus is acidotic on the table. "Safe technique" therefore means far more than knowing the steps: it means a reproducible, evidence-anchored sequence that protects mother and baby, minimises blood loss and infection, and is teachable to the next person on call. CS is not a benign operation — it carries maternal mortality and morbidity well above vaginal birth, and in South Africa caesarean delivery is repeatedly implicated in the Saving Mothers report as a site of avoidable death, principally through obstetric haemorrhage, anaesthetic complications, and sepsis.
The objective here is descriptive: you must be able to walk through a safe CS from decision through closure, justify each step against evidence where it exists, and — explicitly named in the objective — describe the various skin incisions and when each is chosen. The chapter is structured to let you recite the operation as a coherent narrative, the way you would teach a junior in the scrub room, while signposting the few steps that genuinely change outcomes. Related perioperative and procedural detail sits in eras-principles, surgical-instruments-safe-use, electrosurgery-safety and perioperative-fluids; the haemorrhage and rupture sequelae are covered in postpartum-haemorrhage, uterine-rupture and vbac.
Core knowledge
Figure F13.1 — Safe CS entry choice map: match the access to the risk — Joel-Cohen / Misgav-Ladach (routine) vs Pfannenstiel vs midline — open in layers with blunt expansion and a low-transverse uterine entry away from the vessels.
Categorising urgency
Decision-to-delivery interval is driven by a shared urgency classification (the RCOG/NICE four-category scheme): Category 1 — immediate threat to the life of woman or fetus (e.g. cord prolapse, scar rupture, sustained fetal bradycardia, abruption with fetal compromise) — aim to deliver as fast as safely possible, conventionally taught as a 30-minute target; Category 2 — maternal or fetal compromise that is not immediately life-threatening; Category 3 — needs early delivery but no compromise; Category 4 — elective, at a time to suit the woman and team. The category determines the anaesthetic (general anaesthesia is sometimes unavoidable for a true Category 1) and how much of the WHO Surgical Safety Checklist can be completed without delaying delivery. The 30-minute figure is a clinical audit standard rather than a hard physiological threshold; do not let chasing the clock force a dangerous general anaesthetic when a rapid spinal is feasible.
Skin incisions (named in the objective)
The choice of abdominal entry is a genuine technical decision with trade-offs in access, cosmesis, strength, and speed.
- Pfannenstiel incision — the default for most caesareans. A transverse, slightly curved incision roughly two fingerbreadths (~2–3 cm) above the pubic symphysis, through skin and subcutaneous fat to the rectus sheath; the sheath is incised transversely and dissected off the rectus muscles superiorly and inferiorly, the muscles separated in the midline, and the peritoneum opened (classically higher up, to stay away from the bladder). Advantages: strong (transverse, along Langer's lines), good cosmesis, less post-operative pain, low dehiscence and incisional-hernia rates. Disadvantage: more sharp/blunt dissection between layers, theoretically more bleeding from perforating vessels, and limited vertical access.
- Joel-Cohen incision — a straight transverse incision sited slightly higher than the Pfannenstiel (about 3 cm below the line joining the anterior superior iliac spines), with the deeper layers opened largely by blunt finger dissection and lateral traction rather than sharp dissection. It is the entry used in the Misgav Ladach method and is favoured by the major surgical-technique evidence (CORONIS, Cochrane) for shorter operating time, less blood loss, less fever and reduced analgesia requirements compared with Pfannenstiel.
- Midline (vertical) sub-umbilical incision — a lower-midline laparotomy. Reserve for situations needing rapid entry or wide access: massive haemorrhage, suspected adhesions or placenta accreta spectrum, very preterm or transverse lie needing a vertical uterine incision, peripartum hysterectomy, or when the abdomen must be explored. Faster and almost bloodless to open, but weaker, more painful, higher hernia and dehiscence risk, poorer cosmesis.
The uterine incision is described separately: the low transverse (lower-segment) incision is standard — less bleeding, better healing, lower subsequent rupture risk, and it permits trial of labour later (vbac). A classical (upper-segment vertical) or low-vertical (De Lee) uterine incision is reserved for a poorly formed lower segment (extreme prematurity), transverse lie with back down, dense lower-segment adhesions/fibroids, anterior placenta praevia/accreta, or some perimortem caesareans — and it commits the woman to elective repeat CS because of the rupture risk.
Why technique matters physiologically
Three mechanisms drive most CS morbidity and are the levers safe technique pulls: haemorrhage (the gravid uterus receives ~500–700 mL/min of blood, so an unretracted uterus or a lateral angle extension into the uterine vessels bleeds fast), infection (a contaminated, hypoxic wound in a postpartum immune-modulated woman), and venous thromboembolism (pregnancy plus immobility plus surgery). Each has an evidence-based countermeasure built into the operation.
Assessment
Before the knife
- Confirm indication and consent. Document the indication, alternatives, and material risks (haemorrhage, infection, visceral injury, VTE, implications for future pregnancies including praevia/accreta and rupture). Consent in South Africa is governed by the National Health Act 61 of 2003 (informed-consent); for the emergency where capacity or time is lacking, act in the patient's best interests and document. Confirm gestation, presentation, and placental site (anterior low placenta warns of a vascular lower segment and accreta risk).
- Group and screen / crossmatch per local protocol and bleeding risk; know where emergency O-negative blood is.
- Anaesthetic assessment and choice. Regional (spinal or epidural top-up) is preferred wherever feasible — it avoids the airway risk that drives a disproportionate share of South African anaesthetic maternal deaths flagged in Saving Mothers. General anaesthesia is reserved for true immediacy, regional failure/contraindication, or maternal refusal.
- WHO Surgical Safety Checklist — sign-in, time-out, sign-out. The time-out confirms patient, indication, allergies, antibiotic given, anticipated blood loss and difficulty, and that swabs/instruments will be counted. This is non-negotiable and is the single cheapest safety intervention in the room.
- Position and prophylaxis. Left lateral tilt (~15°) or manual uterine displacement until delivery to avoid aortocaval compression. Bladder catheterisation. Prophylactic antibiotics before skin incision (see Management). VTE risk assessment (eras-principles).
Identifying the difficult abdomen
Anticipate trouble: previous laparotomy/CS (adhesions, bladder adherent and pulled up), morbid obesity (preoperative-performance-status), suspected accreta (anterior praevia + prior CS), full-term fetus deeply impacted in the pelvis (risk of difficult delivery and lower-segment tears), or a back-down transverse lie. Each may change incision choice, the need for senior help, and whether you site a vertical uterine incision.
Management
This is the heart of the descriptive objective. Walk it through as a sequence.
Skin to uterus
- Skin incision — Joel-Cohen or Pfannenstiel for the routine case; midline if rapid/wide access is needed (see Core knowledge).
- Open the layers. In the Joel-Cohen/Misgav Ladach approach, deepen in the midline, then extend the rectus sheath and muscles by blunt lateral finger traction and open the peritoneum bluntly — this is the technique the evidence favours for speed and reduced blood loss.
- Uterine incision. A small (~2–3 cm) transverse incision in the lower segment, then blunt expansion of the uterine incision (preferably cephalad–caudad), which the evidence associates with less unintended extension and less blood loss than sharp/transverse expansion. Stay away from the lateral uterine vessels. If the lower segment is unformed or access poor, choose a vertical uterine incision and accept its consequences for future pregnancies.
Delivery
- Deliver the presenting part, supporting the uterus and using fundal pressure from the assistant; for a deeply impacted head, disimpact from below or use a reverse breech ("pull") technique with senior help; for a high head consider a small dose of tocolytic if the uterus is gripping. Note the time of delivery.
- Clamp and cut the cord. For the non-compromised baby, delayed cord clamping (≈60 seconds) is recommended where the baby and mother are stable; abandon it if either needs resuscitation. Hand the baby to the neonatal team and follow neonatal-resuscitation if needed.
The third stage and haemostasis
- Uterotonic at delivery. Oxytocin is the first-line agent (a slow IV bolus or infusion per local protocol; avoid a rapid undiluted bolus, which causes hypotension). Carbetocin and, where needed, additional agents/misoprostol are alternatives consistent with the South African EML and the NDoH Maternity Guideline.
- Deliver the placenta by controlled cord traction, not manual removal, unless it does not separate — spontaneous/CCT delivery is associated with less blood loss and endometritis than manual removal.
- Uterine closure. Close the uterus in one or two layers; in South Africa most units close in two layers, and two-layer closure is increasingly favoured to optimise scar integrity for future pregnancy/VBAC, though the single- vs double-layer rupture evidence remains debated. Routine exteriorisation of the uterus is not required; in-situ repair is acceptable, exteriorisation is an option (e.g. poor access) — the evidence shows broadly comparable outcomes, with exteriorisation possibly causing more intra-operative nausea but sometimes better visualisation. Check the angles of the incision first — an unsecured angle is a classic source of concealed bleeding.
- Haemostasis and the swab count. Inspect the angles, the uterine incision, the bladder flap, and the adnexa. Ensure the uterus is well contracted. Do the swab and instrument count before closure and again at the end.
Closure
- Peritoneum — non-closure of both visceral and parietal peritoneum is supported by evidence (less operating time, less analgesia, no increase in complications) and is the default in most modern practice.
- Rectus muscles are not sutured back together.
- Rectus sheath — close with a continuous non-locking absorbable suture; this is the strength layer.
- Subcutaneous fat — close only if the depth is ≥2 cm, where it reduces wound complications; otherwise leave it.
- Skin — subcuticular suture or staples per unit practice; routine subcutaneous drains are not recommended.
Bundled evidence-based measures (the safe-CS checklist)
- Antibiotic prophylaxis BEFORE skin incision (single dose of a first-generation cephalosporin per protocol), which reduces maternal infection more than dosing after cord clamping. Add azithromycin where local protocol/evidence supports it for non-elective CS. This sits in the WHO checklist and the NDoH Maternity Guideline.
- Tranexamic acid has an established treatment role in established postpartum haemorrhage (give 1 g IV early — within 3 hours — per the WOMAN trial) (postpartum-haemorrhage). Its prophylactic role at CS is less settled and should follow local protocol rather than be assumed.
- Thromboprophylaxis — early mobilisation, mechanical prophylaxis, and risk-stratified LMWH per protocol; CS is itself a VTE risk factor.
- Normothermia, judicious fluids, early feeding and early catheter removal under an ERAS framework (eras-principles) speed recovery without compromising safety.
South African context
In the South African platform, CS is performed across district (level 1), regional (level 2) and tertiary (level 3) hospitals. District hospitals do high CS volumes, sometimes with the medical officer as primary surgeon and a single anaesthetist — so a defensible, standardised technique and a low threshold to call for senior/blood/transfer help is itself a safety measure. Saving Mothers (NCCEMD) repeatedly identifies obstetric haemorrhage at CS, anaesthetic-related deaths (favour regional, secure the airway, have help), and sepsis as avoidable contributors; the NDoH National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) codifies prophylactic antibiotics, oxytocin, the WHO checklist and referral criteria. HIV status does not change the operative technique — with effective ART and viral suppression there is no need for special "barrier" precautions beyond routine sharps safety and standard precautions; manage according to hiv-in-pregnancy and continue ART. Universal precautions apply to every case regardless of known status.
The peri-mortem / crash drill (make it unmistakable)
If a pregnant woman of ≈20 weeks or more arrests, this is a resuscitative hysterotomy, not an obstetric operation:
- CALL FOR HELP. Start high-quality CPR with manual left uterine displacement.
- If there is no return of spontaneous circulation by ~4 minutes, deliver by ~5 minutes — perform peri-mortem caesarean at the resuscitation site, no anaesthetic, no scrub, midline incision, fastest route to the baby. The aim is to relieve aortocaval compression and improve maternal resuscitation; fetal survival is a secondary benefit. Do not move the patient to theatre; do not wait for the urinary catheter, the swab count, or the checklist. Continue CPR throughout and after delivery. (See resuscitation-in-pregnancy and postpartum-haemorrhage.)
Red flags / pitfalls
- The undelivered or under-secured angle. Lateral extension of the uterine incision into the uterine vessels or broad ligament is a leading cause of major intra-operative haemorrhage. Identify both angles, secure them first, and beware the concealed broad-ligament haematoma after closure.
- The deeply impacted head. Forcing delivery tears the lower segment toward the vagina/bladder/ureter. Disimpact deliberately (push from below, reverse-breech extraction, consider tocolysis) and call for help before you tear.
- The unexpected accreta. Anterior low placenta plus a previous scar is the high-risk combination. If you cut into placenta and it will not separate, do not pull — stop, get senior help and blood, and be ready for hysterectomy. Unrecognised accreta is a Saving Mothers recurring theme.
- Antibiotics given too late. Giving prophylaxis after cord clamping rather than before incision is a common, evidence-defying habit — it increases infection.
- The rapid undiluted oxytocin bolus causes profound hypotension and has caused arrests; give it slowly/diluted.
- The retained swab. A count not done, or done once, is a sentinel event. Count in and count out, every time, even at 3 a.m.
- Choosing general anaesthesia by default. In the SA setting the airway is a documented killer; favour regional unless contraindicated, and never let the 30-minute audit target stampede you into an unnecessary general anaesthetic.
- Aortocaval compression — failing to tilt/displace the uterus before delivery causes maternal hypotension and fetal compromise on the table.
- Treating the classical scar like a low-transverse one. A vertical/classical uterine incision contraindicates future trial of labour (uterine-rupture, vbac); document it clearly and counsel the woman before discharge.
- Skipping VTE assessment. Postpartum surgical patients are high VTE risk; the omitted prophylaxis is the death you find at autopsy.
Evidence anchors
- NDoH — National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024). The South African source of truth: urgency categorisation, prophylactic antibiotics, uterotonics (oxytocin first-line), the WHO checklist, level-of-care and referral.
- Saving Mothers / NCCEMD triennial report. Identifies obstetric haemorrhage at CS, anaesthetic-related deaths (favour regional anaesthesia, airway and help) and sepsis as recurring avoidable contributors; drives SA CS safety practice.
- WHO Surgical Safety Checklist — sign-in / time-out / sign-out; the cheapest, highest-yield safety intervention; embedded in SA practice.
- CORONIS trial and the Cochrane reviews of caesarean technique — underpin the technique choices described here: blunt (vs sharp) abdominal and uterine entry, non-closure of peritoneum, no routine exteriorisation, closing subcutaneous fat only when ≥2 cm, no routine subcutaneous drain. (Standard surgical-technique evidence summarised cautiously; verify trial/threshold specifics against the primary literature before quoting numbers in an exam answer.)
- WOMAN trial (Lancet 2017) — tranexamic acid 1 g IV within 3 hours reduces death from bleeding in established PPH; relevant to CS haemorrhage management (its prophylactic CS role is less settled).
- ERAS Society guidance — perioperative optimisation, normothermia, early feeding/mobilisation, judicious fluids (eras-principles).
- NICE / RCOG urgency categorisation and decision-to-delivery framework — the four-category system and the 30-minute audit standard for Category 1 (an audit target, not a physiological threshold). (Cited as the standard framework; confirm the current NICE caesarean-birth guidance number before quoting in writing.)
- South African EML — Hospital Level — oxytocin, antibiotic prophylaxis agent, analgesia and thromboprophylaxis availability.
- National Health Act 61 of 2003 — consent for the procedure (informed-consent, sa-og-law).