- Grasp bleeders with Green Armitage clamps, identify uterine angles and apply clamps
- Retract the bladder
- Examine the placental site for retained products
- Pack colonic gutters with moist packs as needed
- Exteriorize the uterus if incision is bleeding or if better visualization needed (inform anesthetist as this may induce hypotension)
- Observe for PPH, uterine contraction
- Close lower segment in two layers using delayed absorbable suture starting with angle sutures
- Close classical incision in 3 layers
- Replace uterus in abdomen, observe for bleeders before closure
The edges of the uterine incision will be bleeding briskly at this point. Grasp any obvious bleeders with Green Armitage clamps. Identify the angles of the incision and secure them with sutures. The incision itself is closed with two layers of continuous absorbable suture (usually Vicryl 1-0). The cut edges of the incision are usually approximated with a running, locking suture. The second layer uses a running (unlocked) suture.
The uterus may be externalized to facilitate exposure and reduce bleeding during closure.The externalized uterus places the uterine blood supply on stretch and decreases bleeding at the incision site. Once closure is complete, the uterus is replaced and observed for hemostasis. More sutures are added as required.
Closure of a Classical Incision in 3 Layers
A classical incision will be considerably thicker. It typically requires three layers and additional figure-of-8 interrupted sutures to secure good hemostasis.