Exteriorisation of the uterus, incision and delivery

Exteriorisation of the uterus

Dependent on the location of the upper placental border, the intended uterine incision site and ease of access to the surgical field, the decision may be taken to exteriorise the uterus to facilitate delivery of baby.  

Exteriorising the uterus is part of the SAC technique.  This allows placement of a vertical fundal incision at maximal the distance from the placental bed, whilst also allowing the access and manoeuvrability to perform a safe delivery which is usually by breech extraction.  

Exteriorisation may not be suitable in cases with extensive pelvic neo-vascularisation due to the risk of provoking bleeding when manipulating the uterus.

Video of uterine exteriorisation through the transverse SAC incision

Uterine incision

The fundamental principle for making the incision is avoidance of the placenta. As the majority of the cases will be previa/PAS this means an upper segment or 'classical' incision.

Dependent on the location of the upper placental border, the intended uterine incision site and ease of access to the surgical field – the decision may be taken to exteriorise the uterus at this stage to facilitate delivery of baby. 

Exteriorising the uterus is part of the SAC technique. This allows placement of a fundal incision at maximal the distance from the abnormal placental bed; whilst also allowing the access and manoeuvrability to perform a safe delivery via breech extraction (see video). 

Exteriorisation may not, however, be suitable in cases with extensive neo-vascularisation extending out into the broad ligament, pelvic sidewall or parametrium the  due to the risk of provoking bleeding when manipulating the uterine position .

Delivery

A small incision is made in the fundus of the uterus down to the membranes (Fig 1). The incision is then carefully extended using a linear cutting stapler to minimise the blood loss from the hysterotomy (Fig 2 and 3). NB the assistant should place their fingers inside the uterus in the direction that the incision is to be made, then the stapler is passed over their fingers and applied. This ensures there is no risk of no accidental trauma to the baby. If this is not available, the edges of the incision are immediately clamped with Green-Armitage clamps to reduce blood loss.

Delivery is usually by gentle breech extraction. As with any breach delivery care should be taken when handling the baby to avoid any trauma (see video).  

Fundal incision with Cutting stapler and delivery video

Delayed Cord Clamping

Delayed cord clamping, only cutting the cord after 1 minute, has has been demonstrated to improve neonatal outcomes. 

If the delivery is significantly pre-term or the baby anticipated to be small, a transwarmer device wrapped in sterile drapes and placed on the woman's abdomen can be used to ensure the newborn does not become hypothermic during this time. The baby is then passed immediately to the waiting newborn  team.

Closure of Hysterotomy

See Step 13