Key Components of Cesarean Section Management
Effective cesarean section management requires adherence to evidence-based protocols for preoperative, intraoperative, and postoperative care to minimize maternal and neonatal morbidity and mortality. 1
Preoperative Management
Antimicrobial Prophylaxis and Skin Preparation
- Administer intravenous antibiotics within 60 minutes before skin incision:
- Use chlorhexidine-alcohol for abdominal skin preparation (preferred over povidone-iodine) 1, 2
- Consider vaginal preparation with povidone-iodine solution to reduce post-cesarean infections 1
Fasting and Preoperative Nutrition
- Clear liquids permitted up to 2 hours before surgery
- Light meal allowed up to 6 hours before surgery
- Consider carbohydrate drink for non-diabetic patients up to 2 hours before planned cesarean 2
Thromboprophylaxis
- Apply mechanical venous thromboembolism prophylaxis preoperatively
- Continue until patient is fully ambulatory 2
- Consider low-molecular-weight heparin for high-risk patients 1
Intraoperative Management
Anesthetic Technique
- Regional anesthesia is strongly preferred over general anesthesia 1
- For pregnant women after 20 weeks:
- Position with left uterine displacement to prevent aortocaval compression
- Ensure adequate maternal oxygenation and optimal uteroplacental perfusion 1
Prevention of Hypothermia
- Implement active warming measures:
- Monitor patient temperature throughout procedure 1
Surgical Techniques
- Blunt expansion of transverse uterine hysterotomy to reduce blood loss
- Consider two-layer closure of hysterotomy to reduce risk of uterine rupture
- Peritoneum does not need to be closed (increases operative time without improving outcomes)
- Reapproximate subcutaneous tissue if ≥2 cm thick
- Use subcuticular suture for skin closure to reduce wound separation 1
Fluid Management
- Maintain euvolemia throughout procedure
- Avoid both under-resuscitation and fluid overload 1
Immediate Neonatal Care
- Perform delayed cord clamping:
- At least 1 minute for term deliveries
- At least 30 seconds for preterm deliveries
- Maintain neonatal body temperature between 36.5°C and 37.5°C
- Avoid routine suctioning of airway or gastric aspiration
- Ensure capacity for immediate neonatal resuscitation 1
Postoperative Management
Pain Management
- Multimodal analgesia approach:
Prevention of Hemorrhage
- Consider prophylactic tranexamic acid (1g IV or 10mg/kg) for patients at high risk of postpartum hemorrhage 2
Early Recovery Measures
- Remove urinary catheter promptly
- Encourage early ambulation
- Allow regular diet within 2 hours postoperatively 3
- Resume oncological treatment (if applicable) within days after vaginal delivery or 7 days after uncomplicated C-section 1
Special Considerations
Cesarean in Cancer Patients
- For patients with gynecologic cancers (especially cervical cancer), C-section may be indicated to avoid tumor laceration, excessive bleeding, or obstruction of the birth canal
- Consider corporeal uterine incision to avoid surgical trauma of the lower uterine segment in patients with cervical cancer 1
- Examine placenta for metastatic disease 1
Timing Considerations with Chemotherapy
- If the patient is receiving chemotherapy:
- Pause 3-weekly regimens around 35 weeks
- Pause weekly regimens by 35-36 weeks
- Wait 2-3 weeks before delivery to avoid myelosuppression 1
Potential Complications and Risks
- Higher maternal mortality and morbidity compared to vaginal birth
- Increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth in subsequent pregnancies
- Potential long-term effects on children including altered immune development, increased likelihood of allergy, asthma, and reduced intestinal microbiome diversity 4
By implementing these evidence-based practices, healthcare providers can optimize cesarean section outcomes and minimize complications for both mother and baby.