Uterine Exteriorization During Cesarean Delivery: Indications and Technique

Exteriorizing the uterus (temporarily bringing it through the abdominal incision) is a standard step in many cesarean deliveries, though not universal.

Primary Reasons

1. Optimal fetal access: Elevates uterine fundus to incision level → easier delivery of vertex/breech, reduces uterine extension/tear risk.
2. Hemostasis: Direct visualization of uterine incision → precise suture placement; bilateral uterine artery compression if needed.
3. Uterine inspection: 360° assessment for extensions, rupture, anomalies, fibroids.
4. Placental delivery: Manual removal (standard) or controlled cord traction facilitated.
5. Tubal ligation: If requested, easily performed on exteriorized uterus.

When Exteriorization May Be Omitted

• Deep pelvis / high BMI / large uterus – technically difficult.
• Preterm, small uterus – delivery easy in situ.
• Severe adhesions (prior surgeries) – risk of bowel/bladder injury.
• Surgeon preference / training.
• Breech extraction sometimes done in situ (controversial).

Evidence

• RCTs show exteriorization reduces blood loss (mean difference ~100–150 mL) and operative time.
• No difference in postoperative pain, infection, or febrile morbidity.
• Some women report more nausea/vomiting (vagal stimulation) – manageable with antiemetics.

Technique

1. After fetal delivery, grasp uterine fundus (or cornua).
2. Gently elevate through incision; rest on sterile towels on maternal abdomen.
3. Repair hysterotomy (typically 2-layer locking + running closure).
4. Inspect, ensure hemostasis.
5. Return uterus to pelvis; close abdomen.

Exteriorization is a surgeon's tool for safety and efficiency—not mandatory in all cases.