Surgical Approach to Mitigate Risks and Improve Outcomes in Cesarean Section

The global rise in cesarean section (CS) rates has brought with it an increasing number of technically challenging and high-risk procedures. Surgical complexities often stem from prior cesarean scars, peritoneal adhesions, myometrial defects, and placental invasion disorders, as well as postpartum hemorrhage (PPH) secondary to uterine overdistension, fibroids, or abnormal placentation. Addressing these challenges requires not only technical expertise but also systematic preoperative planning and institutional preparedness.

A recent publication by Nieto‐Calvache et al. proposes a standardized surgical protocol to optimize outcomes in patients at risk of complex cesarean delivery. The protocol emphasizes antenatal risk stratification, paramedian pelvic access, meticulous bladder dissection, and individualized strategies for bleeding control. Importantly, it underscores the role of continuous surgical training, self-assessment, and multidisciplinary team learning in maintaining surgical safety and quality.

Preoperative preparation must include identification of patients with potential intra-abdominal adhesions, abnormal placentation, or previous lower uterine segment (LUS) injury. Complex cases—such as those involving anterior placenta previa, fibroids, or placenta accreta spectrum (PAS)—demand advanced surgical proficiency and should ideally be managed in specialized centers equipped with intensive care, transfusion services, and access to general surgeons and urologists when needed.

Among technical refinements, paramedian pelvic access through the preperitoneal plane offers a safer alternative in patients with dense anterior wall adhesions, allowing access to fibrosis-free tissue and facilitating safe bladder mobilization. Similarly, targeted dissection of avascular subperitoneal pelvic spaces—a technique borrowed from gynecologic oncology—reduces the risk of urinary tract injuries, one of the most frequent complications in repeat or complex cesareans.

Effective management of PPH remains central to improving maternal outcomes. Mastery of uterine vascular anatomy, coupled with timely interventions such as uterine compression sutures, tourniquets, and aortic compression, can significantly mitigate blood loss. Adoption of patient blood management (PBM) principles, as highlighted in recent multidisciplinary consensus statements, should be integral to surgical planning.

Ultimately, improving outcomes in cesarean surgery depends on the integration of structured protocols, surgical mentorship, and data-driven quality improvement. Regular video-based review of procedures, structured debriefings, and a culture of safety can transform complex cesarean delivery into a more predictable, controlled, and safer operation for both mother and child.

Source: Nieto‐Calvache AJ, Ramasauskaite D, Palacios‐Jaraquemada JM, et al. International Journal of Gynecology & Obstetrics. 2025 Jan 4.