Creation of the bladder flap, i.e., dissecting the urinary bladder from the lower segment of the uterus is a standard part of CS. However, it is yet to be established whether the formation of bladder flap is advantageous. If direct uterine incision is made, the loose connective tissue between the uterus and the urinary bladder allows the spontaneous descent of the bladder. During this process, no vascular injury occurs.
http://www.drnirajmahajan.com/files/documents/Arch-Obs-Gyn-Bladder-Flap.pdf
I usually incise the inflection, but do not extensively dissect or push the bladder down the lower uterine segment; only about 1-2 CM
I think the formation of bladder flap is advantageous specially for iterative cesarean section. During the first cesarean I agree with dr. Sadler, but if surgery is performed by experienced surgeon. For obstetricians in training it is best to dissect, but not extensively , the urinary bladder from the lower segment of the uterus.
I do not create a bladder flap routinely. There is no evidence that creating a bladder flap is beneficial. The benefits of omitting the bladder flap are likely small (minimal reduction in operative time, slight reduction in blood loss, less microscopic hematuria). My take on it is if there is no benefit why go through the trouble of an additional step?
My notable exception is in the case of a suspected accreta. I then create a bladder flap so that a hysterectomy can be performed more rapidly once the bleeding begins. I will also create a bladder flap if the bladder is adherent high on the anterior surface of the uterus from a previous cesarean.
We have recently published a meta analysis on this issue:
Omission of the bladder flap at caesarean section reduces delivery time without increased morbidity: a meta-analysis of randomised controlled trials.
O'Neill HA, Egan G, Walsh CA, Cotter AM, Walsh SR.
Eur J Obstet Gynecol Reprod Biol. 2014 Mar;174C:20-26. doi: 10.1016/j.ejogrb.2013.12.020. Epub 2013 Dec 22. Review.
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