Why? Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout. Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed. Hysterotomy — lower uterine segment, lateral uterine vessels to avoid Delivery baby — delay cord clamp, placenta Likely lots of bleeding — same atony meds as vaginal delivery Clean inside of uterus to remove all membranes etc. Possibly exteriorize uterus to see better — depends on scaring How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures. Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis. Clean up the abdomen–irrigation vs moist laps vs suction Now to close: Peritoneium — either way, close or not– no evidence either way Muscle– don’t close, evidence that closing it can cause hematoma Fascia–Close! Closing Fascia: Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection Skin closure — stables, suture, absorbable stables