Technique for Classical CS

Abdominal Incision: Vertical Midline

The lower abdominal midline incision should be employed if optimal exposure is desired. It is generally thought to be faster and easier to perform in the case of an emergency classical cesarean section. It can be easily extended to afford exposure of the entire peritoneal cavity. It will generally produce less blood loss than the Pfannenstiel because no large perforating vessels need be divided. The midline is relatively avascular. The disadvantages of the midline begin as the surgery ends with longer time for wound closure, higher rates of wound breakdown and hernia formation.

  • Vertical Incision
    • Lower abdominal midline
    • Generally faster
    • Better exposure
    • Easy to extend if needed
    • Less blood loss
    • Poorer healing

Uterine Incision

Classical cesarean accounts for only 1% of cesarean sections.  It is reserved for those rare instances when a lower segment incision is impossible or contraindicated.  These circumstances may involve fetal factors where the presenting part has not adequately advanced to distend the lower uterine segment.  This may occur with prematurity (particularly <30 weeks gestation, footling breech presentation, transverse lie or a combination of these factors.  Closure of the incision is more difficult and involves more blood loss due to the thickness of the myometrium in the upper uterine segment.  Once a classical cesarean section has been performed, future trial of labour is contraindicated.

  • Classical (Vertical)
    • Excellent exposure
    • Avoids injury to large uterine vessels caused by extension of a transverse incision
    • Useful when lower segment is not developed
    • Once a (classical) cesarean, always a cesarean
    • Thick myometrium means slower entry
    • May need to cut through the placenta to access the uterus
    • More difficult closure (three layers)

The uterus has a copious blood supply.  There are large vessels that anastomose along the lateral borders.  For this reason, lateral extension of a transverse incision is likely to cause significant hemorrhage.  The classical (midline) incision avoids this complication.

Cesarean Delivery and Peripartum Hysterectomy, Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. Williams Obstetrics, 25e; 2018. Available at: Accessed: November 07, 2019
Copyright © 2019 McGraw-Hill Education. All rights reserved

The vertical incision is made in the midline of the body of the uterus cephalad to the bladder reflection.  Again successive, superficial cuts with the scalpel are made until the cavity is entered.  The incision is then extended with bandage scissors. If a transverse incision has already be made it can easily be converted to a classical by clipping in the midline with bandage scissors, converting to in inverted “T” incision.

Internal Podalic Version

Transverse lie is a bit trickier than simple breech extraction and usually involves grasping the ankles and converting the lie to breech by internal podalic version.

Transverse lie is converted to breech by grasping one or both ankles.

  • Try to keep membranes intact if that is an option
  • May need tocolysis/uterine relaxation to facilitate manipulation
  • Internal podalic version as the assistant applies transabdominal pressure on the head to aid fetal rotation into a breech position
  • Avoid hyperextension of the neck
  • Do breech extraction

Grasp the baby’s ankles and bring the feet into the incision while an external hand pushes the head toward the uterine fundus. 

Uterine 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 three layers of continuous absorbable suture. Additional interrupted sutures can be added. The uterus may be externalized to facilitate exposure and reduce bleeding during closure.

  • Exteriorize the uterus
  • Close incision in 3 layers or more
  • Uterus is thick and will bleed more than with LSCS
  • Replace uterus in abdomen, observe for bleeders
  • Press hot foments against incision if oozing
  • Pressure, patience, platelets, prayer

Closure of a Classical Incision in 3 Layers

A classical incision will be considerably thicker than a lower segment incision.  It typically requires three layers and additional figure-of-8 interrupted sutures to secure good hemostasis.

Updated on July 27, 2023

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