What are the current guidelines for a caesarean section procedure?

Current Guidelines for Caesarean Section Procedure

Intravenous antibiotics should be administered routinely within 60 minutes before the caesarean delivery skin incision, with a first-generation cephalosporin recommended for all women and additional azithromycin for women in labor or with ruptured membranes. 1

Preoperative Management

• Chlorhexidine-alcohol is preferred to aqueous povidone-iodine solution for abdominal skin cleansing before cesarean delivery 1
• Vaginal preparation with povidone-iodine solution should be considered for the reduction of post-cesarean infections 1
• Clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery 2
• Consider preoperative carbohydrate drinks for non-diabetic patients up to 2 hours before planned cesarean delivery 2
• Hair removal at the incision site is not necessary, but if preferred, clipping or depilatory creams should be used rather than shaving 2

Anesthesia and Pain Management

• Regional anesthesia is the preferred method for cesarean delivery as part of an enhanced recovery protocol 1
• Add intrathecal morphine 50–100 μg or diamorphine 300 μg to spinal anesthesia for postoperative pain management 1
• Prescribe paracetamol and NSAIDs administered after delivery and continued regularly postoperatively 1
• Administer a single dose of intravenous dexamethasone after delivery in the absence of contraindications 1
• Consider local anesthetic infiltration, continuous wound local anesthetic infusion, and/or fascial plane blocks if intrathecal morphine is not used 1

Intraoperative Management

Prevention of Hypothermia

• Appropriate patient monitoring is needed to apply warming devices and avoid hypothermia 1
• Forced air warming, intravenous fluid warming, and increasing operating room temperature are all recommended to prevent maternal hypothermia 1
• Maintain neonatal body temperature between 36.5°C and 37.5°C after birth 1

Surgical Techniques

• Blunt expansion of a transverse uterine hysterotomy is recommended to reduce surgical blood loss 1
• Closure of the hysterotomy in 2 layers may be associated with a lower rate of uterine rupture 1
• The peritoneum does not need to be closed as closure is not associated with improved outcomes and increases operative times 1
• In women with ≥2 cm of subcutaneous tissue, reapproximation of that tissue layer should be performed 1
• The skin should be closed with subcuticular suture in most cases 1
• Use Joel-Cohen incision technique when possible for reduced postoperative pain 1

Fluid Management

• Perioperative and intraoperative euvolemia are important factors in patient care and appear to lead to improved maternal and neonatal outcomes 1

Neonatal Care

• Delayed cord clamping for at least 1 minute at term delivery is recommended 1
• Delayed cord clamping for at least 30 seconds at preterm delivery is recommended 1
• Routine suctioning of the airway or gastric aspiration should be avoided and used only for symptoms of an obstructive airway 1
• Routine neonatal supplementation with room air is recommended 1
• In all settings that perform cesarean delivery, a capacity for immediate neonatal resuscitation is mandatory 1

Postoperative Care

• Consider transcutaneous electrical nerve stimulation as an analgesic adjunct 1
• Use abdominal binders for improved pain management 1
• Implement strategies to minimize systemic opioid utilization 1
• Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg IV) is recommended prophylactically for patients at high risk of postpartum hemorrhage 2
• Mechanical venous thromboembolism prophylaxis is recommended until the patient is ambulatory 2

Common Pitfalls and Caveats

• Antibiotics were historically given after cord clamping due to concerns about fetal exposure, but evidence now strongly supports administration before skin incision to decrease wound infections 1
• The benefits of local and regional analgesic techniques are not apparent when intrathecal morphine or diamorphine is used, so these techniques should be reserved for cases where neuraxial opioids are contraindicated 1
• Classical (vertical) cesarean section should only be considered in specific cases such as preterm labor, dense adhesions, or placenta previa/accreta where access to the lower uterine segment is difficult 3
• Women with prior classical cesarean section are contraindicated for trial of labor after cesarean section due to increased risk of uterine rupture 3