How to avoid placental transection during low transverse cesarean delivery for anterior placenta previa.

Abstract

Placenta previa, particularly when anterior, is a major risk factor for postpartum hemorrhage and may necessitate transplacental fetal extraction during cesarean delivery, which increases maternal and fetal blood loss. Standard strategies to minimize bleeding, such as fundal uterine incisions (when placenta accreta spectrum is suspected) or intraoperative ultrasonographic guidance, may be technically demanding, time-consuming, or unavailable in emergencies or resource-limited settings. Controlled separation and mobilization of a placental edge to avoid placental laceration offers a simple, reproducible technique to extract the fetus through a standard low transverse uterine incision without transecting the placenta. The procedure begins with prenatal mapping of the placental edge closest to the planned hysterotomy. A low transverse segmental hysterotomy is then performed, followed by controlled placental separation toward the nearest placental edge, rupture of the amniotic sac, exteriorization of the detached placental edge, and routine fetal extraction. Avoiding placental transection can reduce maternal blood loss, facilitate delayed cord clamping, and decrease neonatal anemia associated with difficult extractions. Graphic material in the text illustrates the additional bleeding caused by conventional transplacental extraction, emphasizing the potential clinical advantage of this maneuver. It also illustrates the full surgical sequence, from prenatal planning to intraoperative execution. This technique can be incorporated into low-cost, simulation-based training programs and has minimal impact on the incision-to-delivery interval when performed by trained personnel. Although the benefits of this maneuver require confirmation in larger studies, it represents a practical, low-complexity alternative for fetal delivery in anterior placenta previa and other complex scenarios, such as the presence of uterine fibroids, supporting its inclusion in the obstetrical surgical armamentarium.