Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Cesarean birth is an operation that will likely 
be necessary in any setting where childbirth occurs.  
The clinician must consider the risks versus benefits 
for the mother and the infant given the resources 
available for each in the setting of care.  Risks to the 
mother 
in 
the 
short 
term 
(infections, 
thromboembolism, surgical risk, death) and in the 
long term (risk of uterine rupture in subsequent 
pregnancies, risk of abnormal placentation in future 
pregnancies) should be weighed carefully against 
potential benefits to the mother and infant in making 
the decision to proceed with Cesarean birth.  
Indications for Cesarean birth are the following: 
● Maternal hemorrhage 
● Fetal-pelvic 
disproportion 
with 
abnormal 
progression of labor 
● Uterine rupture 
● Fetal malpresentation that cannot be resolved 
with rotation 
● Nonreassuring fetal status 
● Umbilical cord prolapse 
● Mechanical obstruction to vaginal birth (e.g. 
fibroids) 
● Previous Cesarean deliveries* 
*This is not an absolute indication unless previous 
Cesarean was a classical uterine incision (see 
below,) but labor in a patient with a prior Cesarean 
carries a risk of uterine rupture which may be 
unacceptable in many settings. 
 
Perimortem or resuscitative Cesarean is a 
potentially life-saving surgery in the event of cardiac 
arrest in a pregnant individual. It is indicated in 
pregnancies that are 20 weeks or more advanced 
(uterus at the umbilicus) since the gravid uterus can 
impede blood flow at this gestational age.  Previously 
ineffective resuscitative efforts may be effective 
once the uterus is no longer gravid. A perimortem 
Cesarean needs to be performed quickly after 4 
minutes of cardiac arrest with unsuccessful 
resuscitation. The Cesarean should be performed 
simultaneously while cardiopulmonary resuscitation 
is being done.  
The following describes the steps for a 
standard Cesarean birth and what to do when more 
complicated scenarios present themselves.  
 
Steps:  
 
 
1. Administer prophylactic antibiotics.  Ideal 
preoperative antibiotics are a first-generation 
cephalosporin (e.g. cefazolin 1g IV for patients 
<80 kg, 2-3g IV for patients > 80 kg) 
administered in the hour prior to surgery. If 
membranes have been ruptured, azithromycin 
500mg IV should be added if available to reduce 
the risk of perioperative infection. 
2. Place an indwelling catheter. Drain the bladder 
with an in and out catheter prior to surgery if an 
indwelling catheter is not available.  
3. Consider thromboembolism prophylaxis. If 
available, pneumatic compression devices should 
be placed. 
4. Prepare and drape the abdomen and pelvis. 
Abdomen should be prepared with surgical 
solution typically used in the facility. For patients 
in labor with ruptured membranes, performing a 
vaginal preparation as well helps to reduce the 
risk of postpartum endometritis and should be 
performed when possible. This should ideally be 
performed with 4% chlorhexidine gluconate 
vaginal scrub but povidone-iodine is a slightly 
less effective acceptable alternative. 
5. Choose a skin incision. Typically, a transverse 
skin incision, either a Pfannenstiel or Joel-Cohen 
type incision is sufficient for a Cesarean birth. A 
vertical incision can be performed if the 
operative physician feels more comfortable with 
this approach or in instances where a transverse 
incision will not provide enough exposure (e.g. 
suspicion for uterine rupture, distorted anatomy 
from fibroids, maternal obesity.) 
6. Ensure that the skin incision is adequate to 
deliver the fetus.  An incision length of 15 cm, or 
the length of an Allis clamp, will be adequate in 
most circumstances. 
7. Once entry into the abdomen has been achieved, 
place a bladder blade in to expose the uterus and 
assess for the need for a bladder flap. Routine 
creation of a bladder flap has not been shown to 
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
provide any benefit to patients, but for certain 
patients, it may decrease risk of bladder injury. 
Patients who may benefit are the following: 
● Difficult fetal extraction anticipated, with 
chance for extension of hysterotomy 
● Bladder is attached above the lower uterine 
segment from previous Cesarean or anatomic 
differences 
 
To create a bladder flap, identify, then 
elevate the vesicouterine peritoneum, then enter 
sharply with Metzenbaum scissors. Then extend 
the incision laterally and digitally open the space 
between the uterus and the bladder with blunt 
dissection.  Reinsert the retractor’s bladder blade 
between the bladder and the uterus. 
 
Bladder flap peritoneal incision: the peritoneum is lifted off of 
the uterus with a forceps, and the plane between the peritoneum 
and the uterus is then developed caudally, pushing the bladder 
away from the uterus. Source: Hiramatsu, Yuji doi: 10.1055/s-
0040-1708060 
 
8. Decide on what type of hysterotomy will be 
made. The surgeon should know the fetal lie 
prior to making this decision.  In general, a 
transverse hysterotomy in the lower uterine 
segment is the correct uterine incision.  
Transverse hysterotomy results in less blood 
loss and decreases risk of uterine rupture in 
future pregnancies when compared to vertical 
hysterotomy.  The disadvantage of a transverse 
incision is that it cannot be extended if there is 
not enough room without damaging major blood 
vessels. Vertical hysterotomy (low vertical or 
classical incisions) can be considered in the 
following circumstances:  
● Fetal lie is transverse, with back facing 
downwards 
● Dense bladder adhesions 
● Lower uterine segment pathology (e.g. 
placenta previa, large fibroids) 
● Delivery of a very large fetus with risk of 
extension of a transverse hysterotomy into 
the uterine vessels laterally  
Once the hysterotomy is made, extend it bluntly. 
If the uterus is too thick to extend bluntly, 
extend using bandage scissors, taking care to 
avoid the uterine vessels laterally. 
 
Hysterotomy options: low transverse, low vertical, and 
classical  incisions. Source: Kan, Amano doi: 10.1055/s-0039-
3402072 
 
 
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Hysterotomy performed via low transverse incision. Source: 
Hiramatsu, Yuji doi: 10.1055/s-0040-1708060 
 
9. Delivery: After hysterotomy, perform the 
delivery. If the fetus is in a standard cephalic or 
breech presentation, deliver with standard 
delivery maneuvers: 
 
Cephalic:  
● Perform amniotomy   
● The surgeon should use the hand on the caudal 
side of the patient to gently reach inside the 
uterus and cup the fetal vertex.   
● The vertex should then be elevated vertically 
from the hysterotomy. Standing on a stool can 
help to elevate the fetal head vertically (elevating 
obliquely can lead to extensions in the 
hysterotomy and excess blood loss.)  
● After the fetal head has been delivered, deliver 
the remainder of the body through the 
hysterotomy.  
 
The fetal head should be lifted from the hysterotomy vertically 
with the hand on the caudal side of the patient. 
Source:http://www.csh.org.tw/dr.tcj/educartion/teaching/CS/i
ndex.htm  
 
Breech:   
• 
If amniotomy has not been performed, the 
surgeon should attempt to feel through the 
amniotic sac to identify if the presenting fetal part 
is the breech or fetal feet. If the feet are palpable, 
grasp the feet through the sac prior to rupturing 
the membranes. Grasping the feet prior to 
membrane rupture allows for an easier delivery.  
If the membranes are already ruptured and the 
feet are easily palpable, pull the feet and the 
remainder of the fetal legs from the hysterotomy 
using gentle traction.  Often wrapping the feet in 
a moist laparotomy sponge can give additional 
traction. 
• 
If fetal feet are not easily palpable, the surgeon 
can elevate the fetal breech from the hysterotomy 
vertically similar to the delivery of the fetal head 
in a cephalic delivery. If the breech is elevated, 
the legs and feet will follow and spontaneously 
deliver. Gentle traction can then be used on the 
fetal feet to deliver to the level of the fetal 
sacrum. 
• 
Once the fetal body has been delivered to the 
level of the sacrum, rotate the fetal body so that 
the sacrum is anterior. Using the laparotomy 
sponge and gentle traction, grasp the fetus with 
thumbs on the sacrum and index fingers on the 
hips.   
 
The fetus is extracted horizontally with thumbs on the sacrum 
and 
index 
fingers 
on 
the 
hips. 
Source: 
Takeda, 
Jun  doi: 10.1055/s-0040-1702985 
 
• 
Turn the infant 90 degrees to bring the anterior 
shoulder into view, then sweep the arm across the 
fetal chest at the elbow to deliver the arm.   
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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The fetus is rotated 90 degrees to deliver the first shoulder and 
arm. Source: Takeda, Jun  doi: 10.1055/s-0040-1702985 
 
• 
Then rotate the fetus 180 degrees to visualize the 
opposite shoulder and deliver the opposite arm.   
• 
Once both arms have been delivered, an assistant 
should gently hold the fetal body while the 
surgeon delivers the fetal head.  The fetal head 
may deliver easily with minimal traction.  
 
The assistant (left side of picture) holds the fetal body while the 
surgeon 
delivers 
the 
fetal 
head. 
Source: 
Takeda, 
Jun  doi: 10.1055/s-0040-1702985 
 
• 
If the head does not deliver spontaneously, the 
surgeon should use the index and middle fingers 
of one hand to gently press the fetal occiput and 
at the same time, use the same fingers on the 
opposite hand to help to flex the maxilla. These 
movements help to maintain the fetal head in a 
flexed position for delivery. 
 
(Other fetal presentations are described at the end of 
this section.) 
 
10. Clamp and cut the umbilical cord. If no neonatal 
resuscitation is needed and maternal bleeding is 
not excessive, the cord should be clamped after 
30-60 seconds. This delay in umbilical cord 
clamping helps to minimize neonatal anemia. If 
there is active maternal hemorrhage, delayed 
cord clamping should be forgone and the cord 
should be clamped and cut immediately so that 
attention can be turned to hemostasis. 
11. Administer uterotonics and extract the placenta. 
If available, Oxytocin should be administered 
after delivery prior to delivery of the placenta or 
as 
soon 
as 
possible. 
Oxytocin 
10mg 
intramuscularly (IM) or slowly intravenously 
(IV) 5-10 IU as a single dose should be 
administered. Pitocin can also be infused IV, 10-
40 units added to a 500 to 1000mL solution at a 
rate to sustain uterine contraction. The placenta 
should be delivered with gentle traction on the 
clamp on the umbilical cord and fundal uterine 
massage. Manual removal of the placenta should 
be avoided unless rapid removal for bleeding 
control is necessary, since manual removal can 
increase risk of infection and increased blood 
loss.  
12. Close the hysterotomy. The surgeon can choose 
to exteriorize the uterus to close the hysterotomy 
or to repair the uterus in situ. Exteriorizing the 
uterus gives better exposure to suture it but can 
lead to more nausea and vomiting. The uterus 
should be closed in one or two layers, with 
delayed absorbable synthetic suture. The uterus 
should be closed with delayed absorbable 
synthetic suture. The first layer should be placed 
with a running unlocked suture. Locking can be 
considered if there is significant bleeding for 
additional 
bleeding 
control. 
A 
second 
imbricating layer of suture can be used in 
instances where the patient may attempt a vaginal 
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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delivery in the future to help strengthen the 
uterine closure.  If placed, the second layer 
should imbricate the exposed myometrial layers 
and should be a running unlocked stitch. If 
exteriorized, the uterus can be returned to the 
abdomen 
 
Closing the first layer of the hysterotomy. Source: Hiramatsu, 
Yuji doi: 10.1055/s-0040-1708060 
 
 
Closing the second layer of the hysterotomy. Hiramatsu, Yuji 
doi: 10.1055/s-0040-1708060 
 
13. The abdominal wall can then be closed in a 
standard manner. 
 
More Complex Situations 
 
Delivery of a Floating Fetal Head:  
In this situation, the fetal head is moving 
freely above the pelvic inlet. This delivery can be 
difficult because although the head can be accessed, 
it can be difficult to grasp.  The fetus can be delivered 
in one of three ways in this circumstance: 
If membranes are unruptured, the surgeon 
should cup their hand through the uterus around the 
fetal head while membranes are ruptured via 
hysterotomy, to keep the fetus in cephalic position. 
Once the amniotic fluid is allowed to fully release, 
often the uterus will contract around the fetus and 
delivery can be achieved in a standard fashion. 
Internal podalic version can be performed.  
The surgeon reaches into the uterus and grasps one 
or both feet while simultaneously using the other 
hand to guide the fetal head to the uterine fundus. 
The fetus is then delivered as a footling breech (as 
described further below) using standard maneuvers. 
This technique can also be used for a second twin 
delivery when the second twin is unengaged in the 
pelvis.  
 
Internal podalic version consists of reaching through the 
hysterotomy to grasp one or both feet while using the other 
hand to guide the head towards the fundus. Source: Takeda, 
Jun  doi: 10.1055/s-0040-1702985 
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Extraction with vacuum or forceps during 
Cesarean (see Operative Vaginal Delivery.) After 
delivery of the fetal head, remove the vacuum or 
forceps and deliver the remainder of the fetus in a 
standard fashion. 
 
Delivery of a Severely Impacted Fetus:  
These can be some of the most challenging 
Cesarean births. When the fetal head is deeply 
impacted in the maternal pelvis, it creates a suction-
like effect. It most often occurs after prolonged 
second stage of labor or failed operative vaginal 
delivery. If extreme force is used to try to deliver the 
baby in these circumstances, this can lead to maternal 
trauma (damage to the uterus, cervix or vagina) or 
severe injury to the fetus (skull injury, intracranial 
hemorrhage, or death.) 
If an impacted fetal head is suspected prior to 
the Cesarean, the patient should be placed in a frog 
legged position or in stirrups for her Cesarean. This 
allows a second surgeon or experienced assistant to 
assist in applying pressure from below on the fetal 
head to elevate the head if needed. If an assistant is 
not available, the surgeon performing the Cesarean 
can attempt to disengage the fetal head manually 
either prior to starting the Cesarean or after an initial 
delivery attempt. If a second person is disengaging 
the fetal head from below, this should not be done 
until the surgery has started and when help is deemed 
as needed by the operating surgeon.  
The assistant disengaging the fetal head from 
below should take care to press on the fetal head 
ideally using their entire palm to distribute pressure 
uniformly to the fetal head to minimize risk of fetal 
head injury. 
In cases of Cesarean birth with an impacted 
fetal head, care needs to be taken to make the 
hysterotomy sufficiently high. If made too low, the 
“hysterotomy” may actually be made in the vagina 
and will be very difficult to repair, increasing risk for 
injury to major vessels and the bladder. After the 
hysterotomy has been made, the initial delivery 
strategy should be for the delivering surgeon to 
attempt to place their hand around the fetal head and 
deliver it as described above.  Often, it is possible to 
place a hand slightly laterally rather than directly 
behind the pubic symphysis. If delivery with this 
approach is not achieved, one of the two following 
strategies need to be chosen: 
Push method: An assistant uses a gloved hand 
to apply even pressure on the fetal head vaginally to 
disengage the fetal head while the operating surgeon 
elevates the fetal head out of the pelvis for delivery 
once it has been disengaged. 
 
An assistant provides pressure from below to manually 
disengage an impacted fetal head. Note that in this illustration, 
the assistant is using fingers. As described in the text, it is better 
to use the palm of the hand if possible to provide uniform 
pressure to the head and avoid injury. Source: 
https://hetv.org/resources/reproductive-
health/impac/Procedures/Caesarean_section_P43_P52.html  
 
Pull method: Surgeons attempting this 
delivery technique should ideally have practiced it in 
non-emergency situations. Fetal head is disengaged 
from below as previously described.  After the fetal 
head has been disengaged, the surgeon reaches into 
the uterine fundus to grasp the fetal feet which are 
then pulled to perform a footling breech extraction.  
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
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First step of a footling breech extraction: the surgeon reaches 
into the uterus to grasp one or both fetal feet and pull them 
downwards. In this illustration, the arms have been delivered, 
making overall delivery of the head and shoulders easier. 
Source: Lenz F et al. 
https://doi.org/10.1186/s12884-019-2253-3  
 
 
Second step of a footling breech extraction: with the feet 
removed, the legs and hips follow. The head will be removed 
last. Source: Lenz F et al. 
https://doi.org/10.1186/s12884-019-2253-3  
 
Transverse Lie:  
If the fetus is transverse with the back facing 
upwards, delivery can be achieved with a transverse 
hysterotomy.  The surgeon should try to keep the 
fetal membranes intact and grasp the fetal feet 
through the membranes to then deliver in a footling 
breech manner after membranes are ruptured.  If the 
fetus is transverse with the back down, there are no 
limbs to grasp with a transverse hysterotomy, thus a 
vertical hysterotomy needs to be made.  Once the 
vertical hysterotomy is made, fetal feet can be 
grasped and the fetus can be delivered in a footling 
breech manner.   
 
Pitfalls: 
● If a low vertical or classical hysterotomy is 
performed, the patient must be counseled that she 
should not labor in future pregnancies.  This 
would put her at significant risk for uterine 
rupture in a subsequent pregnancy.  In general, a 
repeat Cesarean birth planned for 37 weeks is 
recommended in future pregnancies.  
● If bleeding is noted from the placental site after 
delivery of the placenta, several techniques can 
be used to manage it: 
● Deep compression sutures in a figure of 
eight or box pattern 
● Use of a compression balloon (Bakri or 
several filled foley catheters exiting from 
the vagina) 
● Intrauterine packing: Tie together sterile 
gauzes and pack the uterus with the tail of 
the packing exiting from the vagina.  
Take care to ensure the packing has not 
been sewn into the hysterotomy upon 
uterine closure. 
● If the hysterotomy extends into the uterine blood 
vessels laterally, ligation of the uterine vessels 
may be necessary.  A large curved needle with an 
absorbable suture is used for this.  Ureters and 
bladder are first identified, then suture is passed 
through the lateral lower uterine segment as close 
to the cervix as possible, then back through the 
broad ligament just lateral to the uterine vessels.   
This is done both above and below the 
hysterotomy to control bleeding from the 
extension of the hysterotomy.   
Cesarean Birth 
Lindsey E. Zamora, Annelise Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Uterine artery ligation as described in the text: After 
identification of the ureters, with absorbable suture on a large 
curved needle, suture is passed through the lower lateral uterus 
muscle and broad ligament as close to the cervix as possible, in 
the area shown by the Black circles.  
 
● Thromboembolism is one of the highest causes 
of maternal mortality, and a large proportion 
occur after Cesarean birth.  In many settings with 
limited 
resources, 
pneumatic 
compression 
devices may not be readily available.  In this 
case, graduated compression socks are the next 
best alternative.  All patients should be 
encouraged to ambulate as early as possible after 
surgery to reduce their risk as well.  In patients 
who are at high risk for thromboembolism, it is 
reasonable to consider both mechanical and 
pharmacologic prophylaxis once cleared from an 
anesthesia standpoint. 
 
Lindsey E. Zamora, MD MPH 
Vanderbilt University Medical Center  
USA 
 
Annelise Long, MSPH  
University of Washington 
USA 
 
March 2023 
 
