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

Guidelines for Cesarean Section

Preoperative Infection Prevention

Administer intravenous antibiotics within 60 minutes before skin incision—specifically, a first-generation cephalosporin for all women, with the addition of azithromycin for women in labor or with ruptured membranes. 1, 2

• This represents a critical shift from historical practice: antibiotics were previously given after cord clamping due to fetal exposure concerns, but evidence now strongly supports pre-incision administration to reduce wound infections 1, 2
• Use chlorhexidine-alcohol for abdominal skin preparation rather than aqueous povidone-iodine solution 1, 2
• Perform vaginal preparation with povidone-iodine solution in women in labor or with ruptured membranes, which reduces endometritis risk from 8.3% to 4.3% 1, 2

Anesthetic Management

Regional anesthesia is the preferred method for cesarean delivery, offering superior outcomes for pain control, organ function, and postoperative recovery compared to general anesthesia. 1, 2

• Add intrathecal morphine 50-100 μg to spinal anesthesia for optimal postoperative pain management 2
• Combined spinal-epidural anesthesia allows for more rapid motor recovery while providing capability to extend inadequate blocks 1
• For women with BMI >40 kg/m², antenatal anesthesiology consultation is recommended to discuss limitations and risks 1

Intraoperative Temperature Management

Implement active warming measures to prevent maternal and neonatal hypothermia, which occurs in 50-80% of patients undergoing spinal anesthesia and is associated with surgical site infection, myocardial ischemia, coagulopathy, and prolonged hospitalization. 1, 2

• Use forced air warming, intravenous fluid warming, and increase operating room temperature 1, 2
• Monitor patient temperature appropriately to guide warming interventions 1, 2
• Maintain neonatal body temperature between 36.5°C and 37.5°C after birth 1, 2

Surgical Technique

Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss rather than sharp extension. 1, 2, 3

• Close the hysterotomy in 2 layers, which is associated with lower rates of uterine rupture in subsequent pregnancies—a critical consideration for future reproductive safety 1, 2, 3
• Do not close the peritoneum, as closure provides no benefit and increases operative time 1, 2, 3
• Reapproximate subcutaneous tissue if ≥2 cm thick to reduce wound complications 1, 2, 3
• Use subcuticular suture for skin closure rather than staples, which reduces wound separation 1, 2, 3
• Consider Joel-Cohen incision technique when possible for reduced postoperative pain 2

Fluid Management

Maintain perioperative and intraoperative euvolemia, which improves both maternal and neonatal outcomes. 1, 2

• Establish early venous access during labor for women with BMI >40 kg/m² 1

Immediate Neonatal Care

Delay cord clamping for at least 1 minute at term delivery and at least 30 seconds for preterm delivery. 1, 2

• Avoid routine airway suctioning or gastric aspiration; use only for obstructive symptoms from secretions or meconium 1, 2
• Use room air for routine neonatal supplementation rather than supplemental oxygen, which may cause harm 1, 2
• Ensure immediate neonatal resuscitation capability is available in all cesarean delivery settings—this is mandatory 1, 2

Postoperative Pain Management

Prescribe scheduled paracetamol and NSAIDs postoperatively as part of multimodal analgesia. 2

• Administer single-dose intravenous dexamethasone after delivery unless contraindicated 2
• Consider transversus abdominis plane blocks or continuous wound infiltration if intrathecal morphine was not used 1, 2
• Use abdominal binders for improved pain management 2
• Minimize systemic opioid utilization through multimodal strategies 2

Special Considerations for Obesity

Obesity alone is not an indication for cesarean delivery; encourage normal vaginal birth in the absence of other obstetric or medical indications. 1

• However, informed discussion about mode of delivery is appropriate given higher operative and anesthetic risks of emergency cesarean in this population 1
• Alert operating room staff when patient weight exceeds 120 kg to ensure adequate staffing and equipment 1
• Apply mechanical thromboprophylaxis (pneumatic compression devices) before cesarean when possible, and consider weight-based dosing of pharmacologic thromboprophylaxis rather than BMI-stratified dosing for class III obesity 1
• Allow longer first stage of labor prior to performing cesarean for labor arrest 1
• Perform active management of third stage for all women with BMI ≥30 due to increased postpartum hemorrhage risk 1

Timing Considerations

Do not perform cesarean delivery on maternal request before 39 weeks gestational age in the absence of other indications for early delivery. 4, 5, 6

• In the absence of maternal or fetal indications, vaginal delivery is safe and appropriate and should be recommended 4, 5, 6
• Counsel patients that risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery 4, 5, 6

Critical Pitfalls to Avoid

• Never delay antibiotic administration until after cord clamping—this outdated practice increases wound infection risk 1, 2
• Do not use misoprostol for cervical ripening or labor induction in women with prior cesarean section, as it carries a 13% rupture rate in the third trimester 3
• Classic (vertical) uterine incisions are absolute contraindications to trial of labor in subsequent pregnancies due to substantially higher rupture risk 3, 7
• Ensure single-layer hysterotomy closure is avoided when possible, as two-layer closure reduces future rupture risk 1, 2, 3