Hofmeyr et al wrote a very interesting comparison of the various techniques for performing a cesarean delivery. However, I was struck by the operating times, which, with 1 exception, range from 27.5 to 56.5 minutes. The one exception (the Misgav Ladach technique) involves a good deal of finger dissection, which I find awkward, and only a single-layer uterine closure. It is possible to do a cesarean delivery in 15 minutes without rushing and to include a double-layer uterine closure and a subcuticular skin closure.

The biggest time saver is a 2-layer, 1-suture, 1-knot uterine closure. I tag the closure stitch and then sew away from myself with a locking first layer. Without cutting or tying the suture, I then bring it back with a parallel Lambert-type imbricating stitch, tying the suture to the previously tagged end. The procedure takes 2 minutes and provides a hemostatic closure with no raw edges to invite adhesions.

The second biggest time saver is to avoid electrocautery until the very last. As a cutting tool, the scalpel is a much faster and less destructive way of getting to and partially through the fascia. Typically all those bleeders encountered on entry will have stopped by closure and cautery will not be needed at all.

It is also faster and gentler on epithelial surfaces to use suction or saline rinse, rather than sponges to keep the field clean. Leaving the uterus in the abdomen and making the uterine incision above the bladder, instead of reflecting it, likewise saves time and trauma.

A nice side effect of the aforementioned approach is that pelvic adhesions seem to be very rare, even on higher-order repeats. I have no formal study of the subject but have personally performed more than 4000 cesarean deliveries and nearly always find a completely clean pelvis on reentry.