SMFM Papers

Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques
Antonella Cromi, MD, PhD; Fabio Ghezzi, MD; Edoardo Di Naro, MD; Gabriele Siesto, MD; Giuseppe Loverro, MD; Pierfrancesco Bolis, MD
OBJECTIVE: The purpose of this study was to compare 2 methods of expansion of the uterine incision at the time of cesarean delivery. STUDY DESIGN: Women who underwent a low-segment transverse ce-

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sarean delivery were assigned randomly to have the blunt expansion of the uterine incision by the physician separating the ngers either in a transversal direction or in a cephalad-caudad direction. The primary outcome measure was the incidence of unintended extensions.
RESULTS: The transversal (n 406) and cephalad-caudad (n 405) expansion groups were similar with regard to patient characteristics, indication to surgery, type of anesthesia, and proportion of emergency procedures. No difference in the need for transfusions (0.7% vs 0.7%; P 1.0) or estimated blood loss (440 341 vs 398 242 mL; P

.09) was noted. The incidence of unintended extension (7.4% vs 3.7%; P .03) and blood loss of 1500 mL (2.0% vs 0.2%; P .04) was signicantly higher in the transversal expansion group, compared with the cephalad-caudad group. Transversal expansion was an independent contributor to unintended extension and blood loss of 1500 mL.
CONCLUSION: Because it is associated with less risk of unintended extension and excessive blood loss, expansion of the uterine incision with a cephalad-caudad traction should be preferred to transversal expansion when a cesarean delivery is performed.

Key words: bleeding, cesarean delivery, expansion of uterine incision, extension, surgical technique

Cite this article as: Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol 2008;199:292.e1-292.e6.

esarean delivery is the major surgical procedure most commonly performed in the western world, and the cesarean delivery rate continues to increase, despite efforts to constrain the

From the Department of Obstetrics and Gynecology, University of Insubria, Varese (Drs Cromi, Ghezzi, Siesto, and Bolis), and the Third Department of Obstetrics and Gynecology, University of Bari, Bari (Drs Di Naro and Loverro), Italy.
This research was presented at the 28th annual meeting of the Society for Maternal Fetal Medicine, Dallas, TX, Jan. 28-Feb. 2, 2008. Received Feb. 29, 2008; revised June 1, 2008; accepted July 8, 2008. Reprints: Antonella Cromi, MD, Department of Obstetrics and Gynecology, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy. antonellacromi@libero.it. 0002-9378/$34.00 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.07.013

For Editors Commentary, see Table of Contents 292.e1

trend for more and more operative abdominal deliveries. The procedure is performed so frequently that even modest differences in outcome, which result from an improved technique, are likely to have relevant cost and community effects. The main aspects of the surgical approach to low-transverse cesarean delivery have not changed much since it was rst described by Kerr1 in 1926. However, over the years minor variations of each surgical step have been introduced, and national surveys report that a wide range of techniques are used in current practice.2 Many technical steps are routinely used because they have been accepted for years and simply handed on from trainer to trainee, without questioning the legitimacy of such approaches, which often are based on clinically sound recommendations but are not truly evidence based.3 Extension of the uterine incision at cesarean delivery usually is performed either sharply by cutting laterally and then

slightly upward with bandage scissors or bluntly by tearing the myometrium with the ngers.4,5 Blunt expansion is derived commonly by when the surgeon pulls the index ngers apart from medial to lateral and cephalad at the same time. Anatomic studies indicate that the oblique interlacing muscular bers of the middle layer of the myometrium in the body of the uterus assume an horizontal course inferiorly towards the istmus.6 Thus, because circular and transversely running muscular bundles dominate the lower uterine segment, uterine incision can be widened transversally by separation of the index ngers of the surgeon in the midline in a cephalad-caudad direction as well.7 We speculated that expansion of uterine incision with a vertical traction might have 2 potential advantages. The rst is to avoid greater forward extension of the distal incision because of lack of control of the force magnitude that is applied by the surgeons ngers at the lateral edges of the incision. The second is to minimize tissue trauma by allowing myometrium dissection along natural tissue planes.

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transversal opening of the fascia was made with the scalpel and extended laterally with scissors; the fascial sheath was dissected off the recti muscles either sharply or bluntly; the peritoneum was opened bluntly; a bladder ap was not created routinely; uterine incision was initiated with the scalpel to incise the lower uterine segment transversely for 1-2 cm in the midline; and the cavity was entered bluntly with a ngertip. At this time point, women who were assigned to the transversal expansion technique had the initial uterine incision extended when the operators index ngers were pulled apart from medial to lateral and slightly cephalad. In the cephaladcaudad group, uterine incision was widened by separation of the operators forengers in a cephalad-caudad direction along the midline (Figure 1). The remainder of the procedure was then completed in a standard fashion. Surgical steps included manual delivery of the fetus, spontaneous delivery of the placenta, and uterine exteriorization. Both techniques for opening the lower uterine segment ultimately resulted in a low-transverse uterine incision that was closed with a continuous nonlocking single layer technique. This was followed by continuous nonlocking closure of the fascia with delayed-absorbable suture, suture closure of subcutaneous fat in women with 2 cm subcutaneous thickness, and skin closure by either staples or absorbable subcuticular suture. Maternal demographics, indication for surgery, stage of labor, type of anesthesia, and intraoperative details were recorded in a computerized database that was maintained by trained residents. The adherence to treatment assignment was ascertained systematically from intraoperative records. An extension was dened as any uterine wall defect, either laterally into the uterine vasculature or vertically into the cervix or contractile uterus, that required additional surgical steps to repair. Operators were asked not to consider as an extension any irregularity in the wound edge that required anything more than the standard uterine closure. Both the surgeon and assistant should have been in agreement on the presence of unintended extension; in 292.e2

FIGURE 1

Methods of expansion of the uterine incision

A, Women in the transversal expansion group had the uterine incision extended by the insertion of both index ngers of the operator into the opening who then pulled the nger apart laterally and slightly cephalad. B, In the cephalad-caudad expansion group, a transverse opening of the lower uterine segment was created by separation of the ngers of the surgeon in a cephalad-caudad direction along the midline.
Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

We therefore designed a study to compare 2 methods of expanding the uterine incision (blunt extension by separating the ngers in a transversal vs cephalad-caudad direction) at the time of cesarean delivery.

M ATERIALS AND M ETHODS

Between November 2005 and July 2007, all women who underwent a low-segment transverse cesarean delivery after 30 weeks of gestation were offered the opportunity to participate in this trial. The study was conducted at a university referral center that manages approximately 1800 deliveries annually. The cesarean delivery rate in our unit approaches 30%. The population that is served by the hospital roughly corresponds to the national Italian population in terms of social class distribution and ethnicity. The study was approved by the Institutional Review Board of University of Insubria. All patients who were scheduled for an elective procedure were enrolled on admission on the morning of the procedure, after providing written informed consent. To overcome the problem of in-

sufcient time to counsel the patient properly in case of emergency procedure, written and verbal information about the trial were provided to all women who were admitted to hospital in labor or for induction of labor or for obstetrics complication intervention after 30 weeks of gestation. In case of cesarean delivery performed for emergency indications, participants were enrolled at the time that the decision to perform the procedure was made. Volunteers were assigned randomly to have the blunt expansion of the uterine incision using either a transversal traction (transversal group) or a cephalad-caudad traction (cephalad-caudad group). Allocation was on 1:1 basis with a block-randomized computer-generated list. The surgical steps up to the point of uterine incision extension were accomplished in a standard fashion. Briey, skin incision was made with a Pfannenstiel incision; subcutaneous incision and opening were performed with the scalpel as little as possible, with dissection of tissue layers bluntly from medial to lateral; a small

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cases of disagreement, a third team member was consulted to come to agreement. Location and number of unintended extension were recorded, and notation was made if the tear involved the bladder, the cervix, the broad ligaments, or the uterine arteries. Uterine artery injury was dened as disruption of the vessels that required placement of a suture to achieve adequate hemostasis. Blood loss was estimated from the blood that had been collected in the suction device, in the plastic pouches of sterile drapes, and in the saturation of pads and sponges. Excessive bleeding during the procedure was dened as estimated blood loss of 1500 mL. The need for additional stitches to achieve adequate hemostasis after the repair of the uterine incision with a continuous suture was recorded. After delivery of the infant, oxytocin solution that had been prepared with 20 IU/500 mL of saline solution was infused over 30 minutes to prevent uterine atony. The need for additional uterotonic agents for the management of intraoperative uterine atony was recorded systematically. On the rst postoperative day, the hemoglobin value was determined and compared with the admission value. Less experienced operator was dened arbitrarily as an operator who had performed 100 cesarean deliveries. The primary outcome measure was the incidence of unintended extension. Power calculation was based on a previous study in which the unintended extension rate was 12.4%.5 With .05 and 80%, data for 403 patients in each arm were required to demonstrate a difference of 6% between groups. Other outcomes of interest included estimated blood loss, blood loss of 1500 mL, change in hemoglobin value, rate of uterine artery injuries, blood transfusion, and the need for additional suture during or after closure of uterine incision. Statistical analysis was performed with GraphPad Prism software (version 4.00; (GraphPad Software, San Diego, CA) and SPSS software (version 12.0; SPSS Inc, Chicago, IL). The t-test and the Mann Whitney U test were used to compare continuous parametric and nonparametric variables, respectively. Pro292.e3
FIGURE 2

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Flow of participants through each stage of the randomized clinical trial

Assessed for eligibility (n=818)

Excluded (n=7) Enrollment 811 randomized Refused to participate (n= 4) Emergency procedures on admission (n=3)

Allocated to transversal expansion (n= 406) Received allocated intervention (n= 406) Allocation

Allocated to cephalad-caudad expansion (n= 405) Received allocated intervention (n= 405)

Analyzed (n=406)

Analysis

Analyzed (n= 405)

Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

portions were compared with the use of the Fisher exact test. Parameters that presented signicant correlation or a tendency towards association (P .10) with the outcomes of interest were entered into a logistic regression model to select independent predictors. A probability value of .05 was considered to be statistically signicant.

R ESULTS
Of the 818 eligible women who underwent cesarean delivery during the study interval, 4 women declined participation in the study, and 3 women had emergency indications for cesarean delivery on arrival at the triage unit (placenta abruptio, 2 women; hemorrhage from placenta previa, 1 woman) that prevented adequate informed consent because of time limitation. Of the 811 women who agreed to participate, 406 women were assigned to the transversal expansion group, and 405 women were assigned to the cephalad-caudad expansion group (Figure 2). The women in the trial groups were similar for baseline obstetric and demographic characteristics (Table

1). All patients underwent the allocated technique for uterine incision expansion. No patient required either T or J vertical extension of the incision into the upper uterine segment or intended sharp extension to further widen the uterine opening that had been obtained by blunt technique to allow delivery of the fetus. None of the women in either group underwent cesarean hysterectomy. Table 2 displays the comparison of surgical outcomes between groups. Unintended extension occurred in 30 of 406 women (7.3%) in the transverse group and in 15 of 405 women (3.7%) in the cephaladcaudad group. In consequence, more women in the transverse group required additional suture placement (33.2% vs 22.9%). Location of unintended extension was lateral in 28 of 30 women (93.3%) in the transversal group and in 14 of 15 women (93.3%) in the cephaladcaudad group. Of the unintended lateral extensions 16 of 28 women (57.1%) in the transversal group and 9 of 14 women (64.3%) in the cephalad-caudad group were on the right side. Cervical lacerations occurred in 2 (0.5%) and 1 (0.25%)

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TABLE 3
Transversal group (n 406) Cephalad-caudad group (n 405) 32.6 4.9 26.7 4.0 38.3 2.4 344 (84.9%)

TABLE 1

Clinical characteristics of the study groups

Characteristic Maternal age (y)
a

P value .81 .06 .13 .55

..............................................................................................................................................................................................................................................

32.7 4.8 27.3 4.2 38.5 2.6 90 (22.2%)

Univariate analysis of specic risk factors for unintended extension of the uterine incision at caesarean delivery
Variable Previous cesarean delivery Labor stage Not in labor First stage OR (95%CI) 0.7 (0.3, 1.5)

Nulliparous (n)

.............................................................................................................................................................................................................................................. 2a

351 (86.4%)

Body mass index (kg/m ) Gestational age (wk) Labor stage (n) First stage Indication (n)

.............................................................................................................................................................................................................................................. a ..............................................................................................................................................................................................................................................

........................................................................................................... .................................................................................................. ..................................................................................................

Previous cesarean delivery (n) Not in labor

.............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. .....................................................................................................................................................................................................................................

104 (25.7%)

.25

1.3 (0.6, 2.6) 0.6 (0.2, 1.6)

296 (72.9%) 46 (11.3%) 64 (15.8%)

274 (67.6%) 64 (15.8%) 67 (16.5%)

.11 .06 .77

.................................................................................................. ...........................................................................................................

Second stage

1.1 (0.5, 2.4)

Second stage

Nonvertex fetal presentation Transversal expansion Emergency procedure

0.7 (0.3, 1.8) 2.0 (1.1, 3.8) 1.1 (0.6, 1.9) 0.9 (0.3, 1.9) 9.9 (4.7, 22.6)

...........................................................................................................

Malpresentation Fetal distress Dystocia Other

..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................

62 (15.3%)

57 (14.1%)

.69

...........................................................................................................

91 (22.4%)

87 (21.5%)

.80

Previous cesarean delivery

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

89 (21.9%)

101 (24.9%) 88 (21.7%) 72 (17.8%)

.32

...........................................................................................................

87 (21.4%)

.93

Less experienced operator

...........................................................................................................

77 (19.0%)

.72

Regional anesthesia (n) Operating time (min) Birthweight (g)

a

.............................................................................................................................................................................................................................................. a ..............................................................................................................................................................................................................................................

357 (87.9%) 53 (13.0%)

365 (90.1%) 48 (11.8%)

.37

Macrosomic fetus (4000 g)

38.9 11.9

40.4 11.8

.15

Less experienced operator (n) Macrosomia 4000 g (n)

.............................................................................................................................................................................................................................................. a ..............................................................................................................................................................................................................................................

.67

Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

3150 554 15 (3.7%)

3112 588 17 (4.2%)

.34

.72

..............................................................................................................................................................................................................................................

Values are reported as mean SD.

Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

women in the transversal group and in the cephalad-caudad group, respectively. Multiple logistic regression was used to model the relationship between group assignment and unintended extension of uterine incision, after we controlled for
TABLE 2

possible confounders. Table 3 shows the results of univariate analysis of risk factors for unintended extensions. Both transversal technique for uterine incision expansion and fetal macrosomia retained statistical signicance when en-

Comparison of surgical outcomes between groups

Outcome Unintended extension (n) Uterine vessels injury (n) Transversal group (n 406) 30 (7.4%) 2 (0.5%) Cephalad-caudad group (n 405) 15 (3.7%) 0 P value .03 .50

.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................

Need for additional stitches (n) Estimated blood loss (mL) Blood loss 1500 mL (n) Blood transfusion (n)
a

.............................................................................................................................................................................................................................................. a .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. a

135 (33.2%) 8 (2.0%) 3 (0.7%)

93 (22.9%) 1 (0.2%) 3 (0.7%)

.001

440 341

398 242

.09

.04

tered into the multivariable regression model (odds ratio [OR], 2.2 [95% CI, 1.1, 4.2] and 10.6 [95% CI, 4.6, 24.5], respectively). We further analyzed the relationship between blood loss of 1500 mL at cesarean delivery and group assignment by controlling for contributors to blood loss at cesarean delivery. The results of univariate analysis of potential risk factors for excessive blood loss (1500 mL) at caesarean delivery are displayed in Table 4. Transversal technique to expand uterine incision and placenta previa as indication to surgery remained predictors of blood loss of 1500 mL when entered simultaneously into a logistic regression model (OR, 8.4 [95% CI, 1.03, 68.6] and 18.5 [95% CI, 4.2, 82.1], respectively). No difference was found between groups in the proportion of patients who required additional uterotonic agents (17/406 vs 13/405; P .58).

Hemoglobin decrease (g/dL)

..............................................................................................................................................................................................................................................

1.2 1.0

1.0 0.8

.05

1.0

C OMMENT
Our results indicate that blunt expansion of uterine incision by exerting a cephalad-caudad traction is associated with 292.e4

..............................................................................................................................................................................................................................................

Values are reported as mean SD.

Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

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lower risks of unintended extension and blood loss of 1500 mL at cesarean delivery, compared with the transversal technique. Options to expand the uterine incision at cesarean delivery have been evaluated in 2 randomized trials that compared sharp vs blunt extension.4,5 The rst trial involved 147 sharp vs 139 blunt uterine incision expansions and found no difference in the rate of unintended extension and postpartum hemoglobin levels.4 However, this study was underpowered to nd signicant differences in this outcomes. A further study, which was published more recently and involved a total of 945 women (470 women who underwent sharp uterine incision expansion and 475 women who underwent blunt expansion), demonstrated that sharp technique was associated with increased estimated blood loss, change in hematocrit level, incidence of postpartum hemorrhage, and risk of inadvertent extensions of the uterine incision, compared with the blunt tecnique.5 Additional postulated advantages of blunt expansion include both speed and less risk of causing injury to the fetus. When the uterine incision is widened, extreme caution should be taken to make the opening wide enough to allow delivery of the fetus, without tearing into the uterine arteries and veins that course through the lateral margins of the uterus. A reported disadvantage of the conventional expansion from medial to lateral by blunt technique is a higher likelihood of extension of the uterine incision onto the uterine vessels if the ngers of the operator are swept too far laterally.8,9 Indeed, by pulling apart the lateral ends of the incision, the index ngers apply the maximum traction force at each lateral edge. Conversely, when pulling forces are exerted vertically, the peak force magnitude is applied along the midline. Under these circumstances, the mechanical resistance to tissue dissection at the lateral margins of the uterus provides a force feed-back that constrains the operators ngers to make further movement that can generate tissue damage. We believe that this force feed-back allowed a widening of the uterine incision in a controlled fashion, even in the presence of a 292.e5 very thin lower uterine segment. On the other hand, when the lower uterine segment was not well-developed, additional force to overcome excessive tissue resistance at the lateral ends could be achieved by sequentially inserting the third and sometimes fourth ngers of each hand on the midline, while pulling in a cephalad-caudad direction, to obtain an adequate opening. Uterine incision extension with a cephalad-caudad traction can decrease the risk of excessive blood loss, both by offering some degree of protection against uncontrolled lateral extension and by minimizing tissue damage, because expansion follows the path of least tissue resistance. The lower proportion of cases that require additional stitches to achieve adequate hemostasis of the uterine scar after closure of the uterus in the cephalad-caudad expansion group seems to support a less traumatic dissection of tissue planes. Moreover, transversal expansion by pulling in a vertical direction can prevent the accumulation of myometrium bers at the ends of the incision as a consequence of a conventional blunt extension that has been considered to increase the risk of sacculation-type defects in the uterine wall.10 We acknowledge the potential for bias in determination of the presence or absence of extension, given the subjective nature of this assessment. We sought to use strict criteria to dene unintended extension to limit the possibility of biases that inuence the evaluation of treatment efcacy. An additional potential drawback of this trial was the use of unintended extension as primary outcome measure, assuming a correlation between this surrogate outcome and maternal morbidity. Clinical judgment and data from previously published studies suggest an association between unintended extension of uterine incision and increased bleeding at cesarean delivery. The higher proportion of women with a blood loss of 1500 mL in the transversal expansion group and the difference between groups in hemoglobin drop after the procedure approaches statistical signicance, which suggests that unintended extension of uterine incision can translate ultimately in higher maternal morbidity. The standardized surgical steps other than
TABLE 4

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Univariate analysis of risk factors for excessive blood loss (>1500 mL) at caesarean delivery
Variable Body mass index 30 kg/m2 Twin gestation Previous cesarean delivery Cesarean delivery during labor OR (95%CI) 1.3 (0.3, 6.3) 1.3 (0.7, 22.2)

........................................................................................................... ...........................................................................................................

2.0 (0.5, 7.4) 1.2 (0.3, 4.4)

...........................................................................................................

Emergency procedure

...........................................................................................................

8.2 (0.5, 141.1) 4.9 (0.3, 91.6)

...........................................................................................................

Placental abruption

...........................................................................................................

Pregnancy-induced hypertension/ preeclampsia Placenta previa

3.3 (0.4, 27.5)

........................................................................................................... ...........................................................................................................

17.7 (4.2, 75.4) 3.1 (0.4, 25.6)

Transversal expansion Macrosomic fetus (4000 g)

...........................................................................................................

8.1 (1.01, 65.2)

Cromi. Blunt expansion of the low transverse uterine incision at cesarean delivery. Am J Obstet Gynecol 2008.

the technique of uterine incision extension and the strict control for variables that are associated potentially with increased blood loss at cesarean delivery confer strength to our results. Our study design did not allow for the collection of information on postoperative complications but for intraoperative outcomes. We acknowledge that having information on postpartum febrile morbidity and/or endometritis and pain medication requirements would have added to the completeness of this randomized comparison. Cesarean delivery is 1 of the oldest surgical procedures in obstetrics and gynecology. Each practitioner develops several renements of the technique that are based mainly on individual experience and expertise. However, it is important to recognize that repetition and habit should not prevent alteration of a technique after one has ascertained the best approach systematically by integrating clinical expertise with the available evidence from well-designed investigational trials. Our ndings demonstrate that blunt expansion of the uterine incision with a cephalad-caudad traction is associated with less risk of unintended

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extension and blood loss of 1500 mL and should be preferred to the conventional expansion in a transversal fashion when lower segment cesarean delivery is performed. These data can serve as the basis for a larger study to conrm whether this renement of cesarean delivery technique confers tangible and worthwhile benets to the patients. f
REFERENCES
1. Kerr JMM. The technique of cesarean section, with special reference to the lower uterine segment incision. Am J Obstet Gynecol 1926;12:729-34. 2. Tully L, Gates S, Brocklehurst P, McKenzieMcHarg K, Ayers S. Surgical techniques used during caesarean section operations: results of a national survey of practice in the UK. Eur J Obstet Gynecol Reprod Biol 2002;102:120-6. 3. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol 2005 ;193:1607-17. 4. Rodriguez AI, Porter KB, OBrien WF. Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section. Am J Obstet Gynecol 1994;171:1022-5. 5. Magann EF, Chauhan SP, Bufkin L, Field K, Roberts WE, Martin JN Jr. Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial. BJOG 2002;109:448-52.

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6. Young RC. Myocytes, myometrium, and uterine contractions. Ann N Y Acad Sci 2007;1101:72-84. 7. Pelosi MA 2nd, Pelosi MA 3rd. Pelosi minimally invasive technique of cesarean section. Surg Technol Int 2004;13:137-46. 8. Clark SL. Cesarean section. In: Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC, Operative obstetrics. Norwalk (CT): Appleton & Lange; 1995:301-32. 9. Abuhamad A, OSullivan MJ. Operative techniques for cesarean section. In: Planche WC, Morrison JC, OSullivan MJ, Surgical obstetrics. Philadelphia: Saunders; 1992:417-29. 10. Field CS. Surgical techniques for cesarean section. Obstet Gynecol Clin North Am 1988;15:657-72.

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