Welcome back to the third and final part of the Cesarean Section Basics series! In this post, we’re covering fetal delivery and abdominal closure. If you haven’t yet, I recommend listening to Part 1, which reviews what happens in the OR before the incision, and Part 2, which walks through the surgical steps up to the hysterotomy.

As always, when I say “evidence supports” or “evidence suggests,” I’m referencing a 2013 systematic review and a 2020 commentary published in Obstetrics & Gynecology, both of which outline evidence-based cesarean techniques. You can find those linked in the show notes.

Let’s dive in.

Delivering the Baby (Vertex Presentation)

Once the hysterotomy has been extended and the membranes ruptured, insert your dominant hand through the hysterotomy and gently elevate the fetal head. Ask your assistant to apply fundal pressure to help bring the head into the incision.

It’s not uncommon for junior residents to struggle with this step. The most common mistake? Not inserting the hand far enough. I always remind my learners: if it’s not coming out easily, try inserting your whole hand in there—you’re not squeezing the head, just palming it to guide it gently.

As more of the head delivers, gradually pull your hand out until only your fingertips are supporting it. Once the head is out, maintain fundal pressure and assist with the delivery of the shoulders. I sometimes hook a finger under the axilla to help shimmy out one shoulder and make room for the other. After that, the body usually follows easily.

I bring the baby up toward the drape and ask anesthesia to lower it so the parents can see their baby. I’ll ask for a towel to clean and stimulate the infant while holding them in a prone position—supporting the chest with one hand and stimulating the back with the other. Gravity helps the baby clear secretions, and this position also helps during delayed cord clamping (usually 60 seconds).

When clamping the cord, I’ll place the baby prone on the drape over the maternal legs before passing them to the bassinet.

👉 Don’t forget to collect cord blood and/or gases before moving on.

Placental Delivery

Evidence suggests the placenta should be delivered spontaneously—meaning gentle cord traction combined with uterine fundal massage, not just waiting or manually removing it.

Manual removal is associated with increased blood loss. Intrauterine wiping with a lap sponge has not shown significant benefit in trials and is generally reserved for when residual membranes are visible (which, in my experience, is pretty often). Use a dry lap over your fingertips and sweep from cornua to cornua, scooping out any remaining membranes.

Uterine Closure

You can close the uterus in situ or exteriorize it. While exteriorization may cause more nausea or vomiting (which can be treated with antiemetics), it may reduce blood loss and improve visualization of surrounding anatomy—benefits that often outweigh the downsides.

For low transverse incisions, there’s no strong evidence supporting single vs. double layer closure in terms of future uterine rupture or abnormal placentation. Use a 1-0 or 0 delayed absorbable suture (e.g., Vicryl), running from apex to apex.

If there’s bleeding, I’ll tamponade vessels with Pennington clamps and may use a second imbricating layer or figure-of-eight sutures to secure hemostasis.

Final Intra-Abdominal Steps

Inspect the adnexa and posterior cul-de-sac for clots, clean with a moist lap, and replace the uterus (if exteriorized). Irrigate the gutters, then inspect the rectus and fascia. I use Kocher clamps on the fascia to visualize any bleeding, which I’ll cauterize or ligate as needed.

Fascial and Subcutaneous Closure

When closing fascia, use delayed absorbable suture—non-absorbable may increase chronic incisional pain. Most surgeons use a running technique; interrupted closure offers no clear benefit and takes significantly longer.

✅ Important: Do not lock the suture. The fascia is avascular and locking increases the risk of strangulation and dehiscence. Suture bites should be no more than 1 cm apart and 1 cm from the edge to avoid tearing.

Irrigate the subcutaneous tissue next. One small RCT showed reduced hematoma/seroma formation with irrigation, though it didn’t change infection rates—still, it’s standard practice where I work.

If the subcutaneous layer is >2 cm thick, closure reduces wound complications and is recommended.

Skin Closure

Evidence now favors subcuticular closure with absorbable monofilament (e.g., Monocryl) over staples. A meta-analysis of 12 RCTs showed reduced wound morbidity with sutures—without differences in pain, cosmesis, or satisfaction.

That’s a Wrap!

That concludes the C-section Basics series! I hope you found this helpful. If you did, consider leaving a review or sharing the episode with a friend or trainee. I’ve had so much fun creating these episodes and look forward to reaching even more learners.

Catch you next Saturday!