In many countries caesarean section has become the mode of delivery in over
a quarter of all births. Safety of the mother and cost are the two main ar
eas of concern. Various studies on the techniques of performing a caesarean
section have focused on reducing the operating time, blood loss, wound inf
ection and cost. Given the fact that caesarean section is the most commonly
performed operation in obstetrics, it is important that trainers and train
ees are familiar with the basic surgical techniques and that best practice
is followed. At the same time surgeons should take necessary precautions to
reduce their risk of exposure to Hepatitis B and HIV.
The skin incision and entry into abdominal cavity is best achieved by the m
odified Cohen's incision. The lower segment transverse uterine incision has
stood the test of time over a period of 75 years and remains the best way
to enter the uterus. Closure of the uterus in single layer appears to be ac
ceptable, whenever technically possible. placental delivery should be by co
ntrolled cord traction after spontaneous expulsion. Closure of the visceral
and parietal layers of the peritoneum no longer seems to be necessary. Obl
iteration of space in the subcutaneous layer, either by suture or by suctio
n, seems to reduce wound disruption, These issues are being considered in t
he CAESAR randomized controlled trial of surgical techniques currently unde
rway in England.
Prophylactic antibiotics are mandatory in preventing post-operative morbidi
ty. Many of the above mentioned steps have been tested in randomized trials
. Further studies are needed to examine a wide range of questions arising f
rom this review, e.g. best position of the patient, the value of exterioriz
ation of the uterus whilst repairing the uterus, and the use of agents to r
elax the uterus in difficult deliveries.