What are the guidelines for a Caesarean (C-section) section?

Guidelines for Cesarean Section

Cesarean section should be performed using a standardized approach that includes blunt expansion of the uterine hysterotomy, closure of the hysterotomy in two layers, non-closure of the peritoneum, and subcuticular skin closure to optimize maternal and neonatal outcomes. 1

Indications for Cesarean Section

Cesarean sections should be performed for clear medical indications, not routinely by maternal request without medical necessity:

• Primary indications include:

  • Dystocia (37%)
  • Non-reassuring fetal heart rate (25%)
  • Abnormal fetal presentation (20%)
  • Failed instrumental delivery (3%)
  • Other indications (15%) 1

• Repeat indications include:

  • No vaginal birth after cesarean attempt (82%)
  • Failed vaginal birth after cesarean attempt (17%)
  • Failed instrumental delivery (0.4%) 1

Preoperative Care

• Administer prophylactic antibiotics 30-60 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 2

• Perform skin preparation with chlorhexidine-alcohol solution 2

• Consider vaginal preparation with povidone-iodine solution for women in labor or with ruptured membranes 1, 2

Surgical Technique

1. Skin Incision:

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

2. Uterine Incision:

   • Transverse incision in lower uterine segment approximately 2 cm above vesicouterine fold
   • Blunt expansion of uterine hysterotomy to reduce surgical blood loss 1, 2

3. Closure Technique:

   • Close the hysterotomy in two layers to potentially reduce the risk of uterine rupture in subsequent pregnancies 1, 2
   • Do not close the peritoneum (closure is not associated with improved outcomes and increases operative time) 1, 2
   • If subcutaneous tissue is ≥2 cm thick, reapproximate this layer 1
   • Close skin with subcuticular suture to reduce wound separation 1, 2

Intraoperative Management

• Maintain normothermia through active warming and increased operating room temperature 1
• Maintain perioperative euvolemia for improved maternal and neonatal outcomes 1
• Delayed cord clamping:
  • At least 1 minute for term deliveries
  • At least 30 seconds for preterm deliveries 1

Postoperative Pain Management

1. Neuraxial Anesthesia:

   • Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anesthesia 1
   • Alternatively, use epidural morphine 2-3 mg or diamorphine 2-3 mg when using combined spinal-epidural technique 1

2. Multimodal Analgesia:

   • Regular paracetamol and NSAIDs after delivery and continued postoperatively 1
   • Single dose of IV dexamethasone after delivery (in absence of contraindications) 1
   • Use opioids only for rescue analgesia 1, 2

3. Additional Pain Control Measures:

   • If intrathecal morphine is not used, consider:
     • Single injection local anesthetic infiltration
     • Continuous wound local anesthetic infusion
     • Fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1
   • Consider transcutaneous electrical nerve stimulation as an analgesic adjunct 1
   • Use abdominal binders to improve comfort 1, 2

Neonatal Care

• Maintain newborn temperature between 36.5°C and 37.5°C 1, 2
• Avoid routine suctioning of the airway or gastric aspiration (use only for symptoms of obstructive airway) 1
• Use room air for neonatal resuscitation rather than supplemental oxygen 1, 2
• Ensure capacity for immediate neonatal resuscitation 1

Special Considerations

Pregnancy in Women with Hypertrophic Cardiomyopathy

• Cesarean section should be reserved only for obstetric indications or emergency cardiac/maternal health reasons 1
• Epidural and general anesthesia are both acceptable with careful attention to avoid hypotension 1

Postoperative Complications and Prevention

1. Thromboprophylaxis:

   • Consider low-molecular-weight heparin, especially in high-risk patients 2

2. Potential Complications:

   • Hemorrhage (4-6% risk with repeat cesarean sections)
   • Infection (reduced with proper antibiotic prophylaxis)
   • Venous thromboembolism
   • Long-term risks: placenta accreta in future pregnancies (0.25-3% risk with multiple cesarean sections), uterine rupture, adhesion formation 2

Conclusion

The cesarean section rate has been steadily increasing worldwide, with potential short-term and long-term health implications for both women and children 3. While cesarean delivery can be life-saving when medically indicated, it carries increased risks of maternal morbidity and mortality compared to vaginal birth 3. Therefore, standardized evidence-based approaches to cesarean section are essential to optimize outcomes and minimize complications.