1. Preparation: Place the patient in the supine position with a right lumbosacral lift to tilt the uterus off the inferior vena cava. Prepare the entire lower abdomen and inguinal areas, and drape the patient in a sterile manner. There is a wide variety of materials and drape sets that are available; familiarity with your site-specific drapes is important (Figure 19-1).

2. Skin and fascia incision: Test the skin and ensure that the patient has complete anesthesia of the operative area. With a No. 10 blade scalpel, make a Pfannenstiel incision 2 cm above the pubic ramus, usually about 15 cm in length (Figure 19-2).

The incision size should be adjusted based on the patient’s habitus and estimated fetal size. Incise the skin and subcutaneous fat down to the fascia. Expect to encounter the inferior epigastric arteries and veins along the lateral aspects of the incision line. These can be either clamped or cauterized for hemostasis. Open the fascia adjacent to the midline linea alba. Incise the fascia down to the rectus muscle, then use Metzenbaum or curved Mayo scissors to bluntly track laterally along the incision path, separating the fascia off the rectus muscle. The scissors are then used to extend the initial fascia incisions laterally, approximating 10 cm in each direction (Figure 19-3). The assistant should use a small retractor to provide lateral exposure for the surgeon to create an adequate fascia incision. When the fascia is opened, it is manually dissected superiorly and inferiorly off the rectus. The linea alba will remain attached at the midline. Clamp the fascia with Kocher clamps and lift the fascia off the rectus, providing counter-traction against the linea alba. Using heavy Mayo scissors, cut the linea alba free, both superiorly and inferiorly from the rectus muscle. Take care not to button-hole the fascia when releasing it from the linea alba (Figure 19-4).

3. Entry into peritoneum: Divide the midline of the rectus muscle and the pyramidalis muscle sharply along the vertical axis using scissors, and manually separate them to expose the peritoneum. Using pick-ups or forceps, lift the peritoneum up and visually confirm the absence of bowel below the thin peritoneal layer. Create a small opening with Metzenbaum scissors or bluntly with the fingers to enter the abdominal cavity (Figure 19-5). After opening the peritoneum, visualize the bladder inferiorly, and place the bladder blade to expose the lower uterine segment. Make a 15-cm transverse incision over the peritoneum that overlies the lower uterine segment. Manually separate the reflection of the peritoneum from the lower uterus to create the bladder flap. The bladder blade is replaced into the bladder flap to protect the bladder and provide exposure for the uterine incision (Figure 19-6).