Today, most CSs are performed using an epidural or spinal anesthesia or combination of both. After anesthesia is administered, the patient should be placed on the operation table with her legs closed. This will prevent tension on the fascia while it is being sutured. The arms of the parturient should not be extended outward in order to prevent neurological damage; this is especially the case when general anesthesia is used [28].

For optimal access to the lower segment of the uterus, and in order to avoid the use of abdominal packs, a Trendelenburg position should be used [29].

After the bladder is emptied with the catheter and the abdomen has been cleaned and covered, the planned site of the incision should be marked. This can be done by pinching or with a pencil, respecting the Langer skin lines [30]. Following these lines will result with an optimal scar. The level of the incision should be drawn in a straight line 3 cm below an imaginary line connecting both spinae iliacae anteriores superiores. The Langer lines become clear when the lateral aspect of the scar is pushed away from the midline. Therefore, marking the planned incision should be done while stretching the skin laterally. In case this line is not clearly marked before stretching the skin, there is a risk that the scar will not be symmetrical and wider on one of the ends.

For ergonomical reasons the right-handed surgeon should stand on the right side of the parturient. When delivering the baby, the more sensitive right hand can easily estimate the needed force to extract the baby, thereby creating less risk for unnecessary extension of the incision of the uterus, avoiding unnecessary extra bleeding. Later, when stitching the uterus, the tip of the needle will point away from the bladder, thus protecting it.

The first incision is done along the marked Langer lines very superficially, cutting only through the cutis (Fig. 14.4). The location is 3 cm below an imaginary line which connects both spinae iliacae anteriores superiores.

This step usually does not require any hemostasis as there are no large blood vessels close to the cutis.

In the midline, where there are anatomically no significant blood vessels, the incision is deepened transversely until the fascia is reached. Then a transverse incision of 2–3 cm is made in the fascia, exposing the recti muscles underneath (Fig. 14.5).

Now a straight scissor with rounded tips is taken in hand.

One tip of the scissors is placed below and the other above the fascia, while the tips of the scissors are opened to about 3 mm (Fig. 14.6). The scissors are pushed toward the assistant, opening the fascia as much as is necessary as estimated by the size of the baby and then repeating this step backward toward the surgeon.

Following this step, the fascia is now open between the straight blood vessels and the muscles. The surgeon inserts both index fingers below the fascia and stretches its leaflets caudally and cranially (Fig. 14.7).

This enables the assistant to insert an index and middle finger below the recti muscles.

The surgeon does the same from his or her side. Now, both, the surgeon and the assistant, pull the muscles laterally, together with the fat tissue and blood vessels as much as needed, again depending on the size of the baby (Fig. 14.8).

Once in a while, more force is needed to pull the muscles laterally, as might happen by repeat operations with fibrosis of the subcutaneous tissues or by overweight women. In this case, four fingers (two fingers from each hand) should be used by both the surgeon and the assistant. The placement of the four fingers should not be next to each other, but one over the other.

Blood vessels have lateral sway, but do not have length elasticity. When both hands are pulling the opening, there is a natural tendency that the hands will move apart, thereby risking blood vessel tearing.

Abdominal packs should not be used, as their usage causes adhesions. The abrasive effect of introducing packs will produce mesothelial trauma which becomes a stimulus for inflammation, followed by adhesions to adjacent surfaces [31, 32].

Not using abdominal packs also ensures that they will not be forgotten inside the abdominal cavity.

The bladder plica should be cut open using a scalpel; in order to expose the plica, a hand speculum should be used, pulling the lower part of the incision down (Fig. 14.9).

Cutting the visceral peritoneum should always be done from the lateral aspects of one side toward the midline and then from the lateral aspect of the other side toward the midline, until it reaches the point where the other side was reached. The reason is that, if it is done the whole way in one direction, there is a risk of cutting into the intestines, as it is difficult to observe clearly the cutting edge of the scalpel. The plica can now be pushed down using two index fingers.

As mentioned, Munro Kerr suggested opening the uterus in its lower segment [33]. In the lower segment, the amount of the fibrous tissue is more dense than in the uterine body. Therefore, the lower the opening in the uterus, the less damage to the myometrium occurs.

Using a scalpel in the exposed lower segment, a transverse incision of about 2–3 cm is done carefully and gently. It is not necessary to complete the incision to the whole thickness of the cervix as this might cut the head or face of the baby which can happen if the membranes have already ruptured and the woman is in active labor, and therefore the lower segment is thin. The final internal part can be penetrated by pushing with one finger through the cut.

Planned CS should be ideally done after the onset of spontaneous contractions. The initiation of labor starts with the initiative of the baby [34, 35].

In predelivery CS one can find not just a thick lower segment, but also maternal breasts which are not yet ready for breastfeeding. There are also other good reasons to avoid pre-labor CS. A recent large cohort study has found that prior pre-labor cesarean delivery was associated with more than twofold significantly increased risk of placenta previa in the following delivery [36]. By contrast, the 20 % increased risk of placenta previa associated with prior intrapartum cesarean delivery was found to be not significant.

The optimal way to complete the opening of the lower segment of the uterus is to extend the initial opening by extension using two fingers (the thumb of the right hand of a right-handed surgeon pushing away and the index finger pulling toward the surgeon). Doing so, the lower segment will open along its natural fibers, which become transverse when it develops, therefore causing minimal bleeding. Cutting with a sharp instrument, like scissors, does not respect the natural anatomy and results with excessive bleeding.

Delivering the baby in vertex position happens while inserting the right hand of the surgeon into the uterus and encircling the head of the baby and then directing the head upward, while slight fundal pressure is allowed. As the right hand has its sensitivity, usually no overextension of the uterine opening will occur, and therefore no unnecessary bleeding happens.

After clamping, drawing blood, and cutting the umbilical cord, the placenta should ideally be delivered spontaneously by assisting through mild traction of the umbilical cord, rather than by manual extraction [37].

Thereafter the uterus should be exteriorated, as in this position it is easier to suture the uterus, to contract it in order to avoid extra bleeding, and also to easily inspect both ovaries.

There are different ways to suture the lower segment. Many of them originate from the already mentioned local traditions. Some surgeons prefer to suture first the angles, followed by two layers of sutures, usually continuously, but sometimes with single stitches to the first or second layer.

The uterus quickly contracts in the first hours after surgery, and after 6 weeks, the uterus returns to its size before the pregnancy. The quick involution results also in shrinkage of the lower segment of the uterus. The sutures are unable to contract along with the uterus, and in a short time after the surgery, they will begin to loosen over the opening line. The aim of the suture is to secure hemostasis in the first postoperative hours. Suture material creates foreign body reaction, and the more of them used, the more marked and longer the reaction, prolonging the healing process. Therefore the less suture material used, the better the healing.

In order to close the uterine wall with the most minimal amount of suture material possible, it is best to use a big needle which will enable closure of the opening and safe hemostasis (Fig. 14.10).

For this reason, it is recommended to use at least an 80 mm needle with an absorbable 1 m-long suture, PGA USP size 1, done continuously. The reason for using a long suture is that it enables placing the knot not at the most lateral aspect of the opening but allows one to go back one or two times in the direction of the midline. Knots placed at the end of the opening might loosen, which will cause bleeding.

There is no point whatsoever for a second layer as long as hemostasis is achieved.

It is not surprising that the dehiscence of previous uterine sutured with one layer is less frequent than those with two layers [38], and a double-layer closure of the cesarean uterine incision does not increase residual myometrium thickness compared to single-layer closure [39].

As no abdominal packs are used, blood clots should be removed with the palm of the hand, and fluid blood will anyhow be absorbed naturally by the peritoneum in a short time, as has been known for many years [40].

The uterus is then repositioned into the abdomen. As long as the uterus is exteriorated, the mechanical tension might disguise active bleeding. Therefore, when the uterus is positioned back into the abdomen, the lower segment should be inspected to ensure that there is no bleeding. Bleeders should be treated with targeted single stitches. There is no justification for a second layer in case of single-sight bleeding.

The abdomen should never be closed before checking the blood pressure of the woman as in low blood pressure bleeding cannot be identified and might occur later when the blood pressure rises. As a rule, the abdomen should not be closed unless blood pressure is normal.

In 1980, Harold Ellis from the Westminster Hospital in London demonstrated that when the peritoneum is left open, a new one will form in short time from the coelom cells underlying the muscles [41].

Unlike the skin, the peritoneum cannot heal by end-to-end approximation. If the peritoneum is left open, a new one will be formed without adhesions.

Our group started leaving the peritoneum open already in 1983. Ten years later, we could compare the rate of adhesions in repeated CS in women who were operated on in the first CS, leaving the peritoneum open and with those in which both peritoneum layers were sutured. In the group where the peritoneum was left open, there was significantly less adhesions [42]. The guidelines of the Royal College advise leaving both peritoneal layers open during closure [43]. In 600 repeated operations, adhesions were found in 7 (11.3 %, in women where the peritoneum was left open during the previous operation) and 22 (35.5 %, in cases where the peritoneum was sutured) [44].

As the peritoneum is left open, just the fascia and the skin must be closed.

Similar to the uterus, there are many variations about how to close the fascia; many of them based on local traditions. Anatomically the fascia was opened above the plica arcuata, and therefore we will find two layers in this level on the lateral sides which should be stitched together. In order to facilitate the stitching, a straight Pean is placed in order to laterally hold both layers, and two other Peans are placed three-fourths of the way toward the assistant (Fig. 14.11).

Knots cause local reaction and irritation. Therefore it is advised to place the lateral initial stitch underneath the fascia. This is done by starting the first stitch from inside to outside, taking both layers together, then from outside to inside.

The first knot is placed below the fascia. The suturing now moves with the needle from inside to outside in continuation through the whole layer. It is advised that the suturing will start at the side of the surgeon toward the assistant. If it is done so, the assistant will hold both of the Peans on the side and lift the fascia, thus guiding the surgeon. The Peans should be held close enough to each other in order to enable suturing without tension, but at the same time, open enough to enable the surgeon to see the underlying structure and to avoid damage to intra-abdominal structures. Once the suture reaches the two lateral Peans, the assistant should remove them and elevate the Pean next to his or her side. In this way, the surgeon, holding the suture material with the left hand, is able to control the needed tension.

There is still no convincing evidence concerning the optimal way to close the skin. Some surgeons prefer using intracuticular suturing which looks at first sight more aesthetic (Fig. 14.12).

However to use this method means subcutaneous sutures are needed. Any sutures and knots are reason for foreign body reaction, and therefore we recommend the use of single Donati silk sutures with a cutting skin needle, and the less placed sutures, the less risk for subcutaneous seromas or hematomas (Fig. 14.13).

The amount of the sutures has to do directly with the experience of the surgeon. Well-trained surgeons can achieve excellent results by using three stitches only, provided they use a big skin needle, where the lateral stitches can be removed after 48 h, resulting in immediate disappearance of local abdominal pain, and the midline suture should be removed after 5 days. The reason that the removal of the lateral stitches will immediately reduce the amount of pain is due to the fact that the skin will swell in reaction to the trauma but the sutures cannot expand with it. As a result there is a constant pinching feeling until the removal of the stitch.

Thereafter, the uterus should be contracted again manually, and the abdominal incision should be covered with a pad which should be replaced 3–4 h after surgery as the wide sutures enable blood to drain from the wound.

Early mobilization is the most optimal way to avoid the complications of vein thrombosis and therefore should be encouraged. CS is a significant risk factor for thromboembolism [45]. Early mobilization can be enhanced by good postoperative pain treatment and removal of the catheter as early as possible. One should encourage early drinking which helps the self-assurance of the mother and function of her intestines [46].

One of the major problems concerning comparison of different surgical methods is the lack of standardization. Different surgeons, even in the same departments, are often using different variations. Therefore, without standardization of the surgical method in use, it will be impossible to compare the outcomes and standardization is the basis for the ability to compare different methods and even comparison between different surgeons and institutions [47].

In order to avoid unnecessary complications, it is important to understand that CS performed in emergency situations are associated with non-favorable short-term outcomes. Many times, such CS are performed when there are already signs of fetal distress, after a long period of pharmacological influence. We must also take into account that emergency CS are often performed in a hurry and very often are associated with non-favorable technical conditions. Furthermore, they are associated with negative long-term complications. According to an American study, women with a full-term second-stage CS have a significant increased rate of subsequent premature births (13.5 %) compared to a first-stage CS (2.3 %) and to the overall national rate (7–8 %) [51]. The same authors have demonstrated that a prolonged second stage of labor alone does not increase the risk of premature birth in following pregnancies. One plausible interpretation is that in case of CS during the second stage of labor, the location of the hysterotomy on the low segment is different from what it is otherwise [52].

This overview of the negative effects of both pre-labor and last-minute emergency CS suggests that the optimal kind of CS is the one performed during labor, before the stage of a real emergency. Until now, the concepts of “planned in-labor CS” and “in-labor non-emergency CS” have not been subject for epidemiological studies. In a multicentered randomized controlled trial about breech presentation at term, only two options were considered: planned pre-labor CS and planned vaginal route [53]. In the extensive Scottish retrospective cohort study of adverse outcomes in childhood, “planned CS delivery” was in fact synonymous with pre-labor CS. It is noticeable that, in this cohort, children born by planned (pre-labor) CS were more likely to develop type 1 diabetes than those born by “emergency” CS or by the vaginal route. The differences were highly significant, even after adjustment for potential confounders, including maternal type 1 diabetes [54]. This data about an autoimmune disorder indicates the need for further studies of the risks of dysregulations of the immune system in relation to “birth without labor.” There is a need, in particular, for a new generation of studies focusing on the risk factors for IgE-mediated atopic syndromes.

On the day when the concept of “in-labor non-emergency CS” becomes familiar, the doors will be opened toward simplified binary strategies, with two basic scenarios: either the birth process is straightforward by the vaginal route or it appears difficult and an in-labor CS before the stage of emergency is considered the best option. Before such simplified strategies become realistic, the history of obstetrics will have to go through several steps. One of these steps will be via studies regarding the long-term side effects of the different medications used during labor. Although there are serious theoretical reasons to reconsider the widespread use of synthetic oxytocin and epidural analgesia, we have not been able to rely, until now, on a large amount of hard data. However, in this new framework, we can already mention valuable studies of the effects of epidural analgesia and synthetic oxytocin, on the initiation and quality of breastfeeding [55, 56]. We can also mention studies looking at risk factors for autism in the perinatal period: while they are based on a great diversity of research protocols in different countries, they all reach similar conclusions about labor induction and labor augmentation [57–61]. The emergence of this new generation of studies (collected in the database “www.​primalhealthrese​arch.​com”) is already offering reasons to use medications during birth with renewed caution, particularly for labor induction and labor augmentation.

The evolution worked in the direction of continuation of generations with as little complications as possible. Many of the complications which happen during labor or CS are iatrogenic in nature. It is important to stress that each maneuver during childbirth or performance for CS should be well indicated. It seems that the active management of labor did not answer expectations, even if the rate of CS was reduced [62].

When considering the case of human birth, the focus should be on the concept of neocortical inhibition, a key to understanding human nature in general. We should keep in mind that some human abilities are usually obscured by neocortical activity. There has been until now a lack of interest in this essential particularity of our species. Human parturition is better understood if introduced in the framework of functions usually obscured by neocortical activity. A first example is offered by olfactory abilities. An ingenious experiment has explored the human sense of smell after neocortical disinhibition by alcohol consumption [63]. Another example is offered by the human swimming abilities: the capacity to adapt to immersion and have coordinated swimming movements when submerged disappears around the age of 3 or 4 months, when the neocortex is reaching a certain degree of maturity [64].

When the concept of neocortical inhibition is understood and taken into account, it is easy to challenge the assumption that mechanical factors are the main reasons for difficult births in our species. In fact, the mechanical factors are undoubtedly overestimated, since there are women with no morphological particularities who occasionally give birth quickly without any difficulty. There are anecdotes of women who give birth before realizing that they are in real labor. There are in particular countless anecdotes of teenagers who, at the end of a hidden or undiagnosed pregnancy, just go to the toilet and give birth within minutes. These facts alone suggest that the main reasons for difficult human births are not related to the shape of the body. The best way to clarify the nature of the specifically human handicap during the period surrounding birth is to consider the case of civilized modern women who have given birth through an authentic “fetus ejection reflex” [65]. It is exceptionally rare in the context of socialized birth. The birth is suddenly preceded by a very short series of irresistible, powerful, and highly effective uterine contractions without any room for voluntary movement. The important point is that when the “fetus ejection reflex” is imminent, women are obviously loosing neocortical control. They become indifferent to what is happening around them. They forget what they have previously learned. They forget their plans. They behave in a way that, in other situations, would be considered unacceptable regarding a civilized woman. For example, they dare to scream or to swear. There are anecdotes of women who have bitten a person perceived as intrusive. Women in hard labor can find unexpected, complex, asymmetrical postures usually involving bending forward. Such scenarios clearly indicate the solution. Nature found to make birth possible in our species: reduced neocortical control. This essential aspect of birth physiology in our species offers an ideal perspective to reach the simple conclusion that a laboring woman needs to be protected against all possible stimulants of her neocortex. Since language is a major stimulant, silence appears as a basic need that is culturally ignored or underestimated after thousands of years of socialization of childbirth. In this respect, rational language and language expressing questions have particularly powerful effects.

Light has not been scientifically studied as a powerful cortical stimulant until recent advances regarding the functions of melatonin, the “darkness hormone.” However, the long history of blinds and curtains is the confirmation of deep-rooted transcultural empiric knowledge that is pushing us, today, to switch off electric lights in order to reduce neocortical activity during sleeping time. Recent studies of the interactions inside the triad oxytocin-melatonin-GABA offer a promising avenue for research. It is already understood that the GABA(A) receptors mediate the effects of melatonin on neocortical activity [66, 67]. Until now, the interactions between the oxytocin and the GABA systems in the perinatal period have been mostly studied in the framework of the shift of the effects of GABA at the end of fetal life, when this primary excitatory neurotransmitter becomes inhibitory [68]. When considering the effects of melatonin, and therefore light, on human parturition, we have to deviate from the concept of neocortical inhibition and refer to recent advances regarding peripheral effects. It is now established that there are melatonin receptors in the human myometrium and that melatonin is synergistic with oxytocin to enhance contractility of human myometrial smooth muscle cells [69–74]. Today melatonin appears as an important hormonal agent in human parturition. This is confirmed by the significant amount of melatonin in the blood of neonates, except those born by pre-labor CS. The importance of these findings appears clearly when the protective antioxidative properties of melatonin are taken into account. In the age of electric lights, the reasons to improve our understanding of melatonin release and melatonin properties are obvious. It is already well established that short-wavelength light (in practice “blue” light) is the most melatonin suppressive. This is an important fact, since it is the kind of light typically emitted by devices such as televisions, computer screens, cellphones, and even lamps in conventional delivery rooms. It is probable that, when birth physiology is better understood, the practical implications of these recent scientific advances will be seriously considered. Until now preliminary practical implications have been limited to attempts to facilitate shift work and also to facilitate the initiation of sleep through the use of amber glasses that block blue light [75, 76]. Can we imagine a time when it will be considered rational to give birth by candle light? Can we imagine a time when women familiar with the use of amber glasses when in front of computer screens will also use such glasses when in labor? After mentioning language and light, we might summarize the most important points by emphasizing that all attention-enhancing situations are stimulants of neocortical activity. This is the case of feeling observed: it implies that one of the basic needs of a laboring woman is privacy. The perception of a possible danger is another example of an attention-enhancing situations: it implies that a laboring woman needs to feel secure. We can notice that similar conclusions can be reached when using the concept of adrenaline-oxytocin antagonism as a starting point.

As a primary objective, reducing the rates of CS is dangerous. The effect is an increased prevalence of difficult births by the vaginal route with an increased need for pharmacological assistance [77]. The first step should be a renewed understanding of the basic needs of laboring women inspired by the physiological perspective: only this perspective can induce a paradigm shift after thousands of years of socialization of childbirth. According to our deep-rooted dominant cultural conditioning, a woman needs cultural interferences to give birth: this is the “helping-guiding-managing-coaching-supporting paradigm.” From the perspective of modern physiology, the keyword is “protection” (of an involuntary process). Such a paradigm shift is the prerequisite for the advent of simplified binary strategies based on the concept of in-labor non-emergency CS. When simplified binary strategies become realistic, there will be new reasons to associate clinical judgements with predictive scores and tests. An American study of predictive scores took into account 11 variables in order to identify, within 2 h after admission, risk factors that place at term nulliparous women in labor at risk for CS. The population was divided into quintiles, in which the lowest risk group had a 5 % incidence and the highest risk group had an 88 % incidence of CS. The objective of this study was clearly to reduce the potential morbidity of long labor or failed operative vaginal delivery [78]. Interestingly it takes also about 2 h to decide, through the “birthing pool test,” if an in-labor non-emergency CS is the optimal option when the first stage is not straightforward. This test is based on the simple fact that when a woman in hard labor enters the birthing pool and is immersed in water at body temperature, a spectacular progress in the dilation is supposed to occur in an hour or two [79]. If the already well-advanced dilation remains stable in spite of water immersion, privacy (no camera!), and dim light, one can conclude that there is no reason for procrastination. It is wiser therefore to perform a CS immediately [80]. In the age of simplified techniques of CS, there are renewed reasons for simplified obstetrical strategies which will reduce, when followed, the rate of neonatal and maternal complications.