What are the steps for a C-section?

Cesarean Section Procedure Steps

A cesarean section should be performed using the Joel-Cohen surgical technique with a Pfannenstiel incision, blunt expansion of the uterine incision, non-closure of the peritoneum, and subcuticular skin closure to optimize maternal outcomes. 1

Preoperative Preparation

• Administer prophylactic antibiotics within 60 minutes before skin incision
  • First-generation cephalosporin (cefazolin 2g IV) for all patients
  • Add azithromycin 500mg IV for women in labor or with ruptured membranes 1
• Perform abdominal skin cleansing with chlorhexidine-alcohol solution 1
• Consider vaginal preparation with povidone-iodine solution 1
• Administer intravenous dexamethasone after delivery (absent contraindications) 2

Anesthesia

• Neuraxial anesthesia is preferred for elective cesarean sections 1
• Add intrathecal morphine 50–100 μg or diamorphine 300 μg to spinal anesthesia 2
• Position patient supine with left lateral tilt (15-30 degrees) to prevent aortocaval compression 1

Surgical Procedure

1. Skin Incision

   • Make a Pfannenstiel (low transverse) skin incision approximately 2-3 cm above the symphysis pubis, extending 12-15 cm laterally 1
   • The Joel-Cohen incision (slightly higher than Pfannenstiel) is associated with reduced operative time, blood loss, and postoperative pain 1

2. Abdominal Wall Entry

   • Incise subcutaneous tissue and fascia
   • Separate rectus muscles in the midline
   • Bluntly dissect the peritoneum to enter the peritoneal cavity 1

3. Uterine Access

   • Push bladder down to expose the lower uterine segment
   • Make a transverse incision in the lower uterine segment approximately 2 cm above the vesicouterine fold 1

4. Delivery of Baby

   • Bluntly expand the uterine incision laterally 2
   • Insert hand into the uterine cavity and elevate the fetal head
   • Apply gentle pressure on the uterine fundus to assist delivery 1
   • Clamp and cut the umbilical cord (consider delayed cord clamping for at least 30 seconds in preterm deliveries) 1

5. Placental Delivery

   • Allow spontaneous separation of placenta
   • Apply gentle traction on cord with counter-pressure on uterine fundus
   • Inspect placenta for completeness 1

6. Uterine Closure

   • Close the hysterotomy in two layers to potentially reduce the risk of uterine rupture in subsequent pregnancies 1
   • Ensure hemostasis of the uterine incision

7. Abdominal Closure

   • The peritoneum does not need to be closed as this does not improve outcomes and increases operative time 1
   • Close the fascia with continuous delayed absorbable suture
   • If subcutaneous tissue is ≥2 cm thick, reapproximate this layer
   • Close the skin with subcuticular sutures 1

Postoperative Pain Management

• Administer paracetamol and NSAIDs regularly after delivery 2
• Consider local anesthetic wound infiltration, continuous wound local anesthetic infusion, or fascial plane blocks if intrathecal morphine is not used 2
• Use transcutaneous electrical nerve stimulation as an analgesic adjunct 2
• Apply abdominal binders to improve comfort 2

Special Considerations

• For preterm deliveries or difficult access to the lower uterine segment, a vertical hysterotomy (classical cesarean section) may be necessary 3
• For patients with portal hypertension, a median low abdominal skin incision may afford lower risks of hemorrhage 1
• For patients with gynecologic cancers, particularly cervical cancer, a corporeal uterine incision is recommended 1

Potential Complications

• Hemorrhage (4-6% risk with repeat cesarean sections)
• Infection (reduced with proper antibiotic prophylaxis)
• Bladder or bowel injury
• Venous thromboembolism (consider thromboprophylaxis with LMWH) 1
• Long-term risks include placenta accreta in future pregnancies (0.25-3% risk with multiple cesarean sections), uterine rupture in subsequent pregnancies, adhesion formation, and incisional hernia 1

By following these standardized steps with careful attention to anatomical layers, hemostasis, and gentle handling of tissues, maternal morbidity can be minimized and neonatal outcomes optimized.