What are the recommended pre-cesarean care protocols?

Pre-Cesarean Care Protocols

Administer intravenous antibiotics within 60 minutes before skin incision—specifically, weight-based cefazolin (2g for patients with obesity or ≥80kg, 1-2g for others), with adjunctive azithromycin 500mg IV added for patients in labor or with ruptured membranes. 1

Preoperative Preparation Timeline

Patient Preparation Before Hospital Arrival

• Showering: Patients should shower with soap or antiseptic solution at least the night before the procedure 2
• Hair removal: If necessary, use clipping or depilatory creams rather than shaving at the incision site 2
• Bowel preparation: Preoperative enema is NOT recommended 3

Fasting and Nutritional Management

• Clear liquids: May be consumed up to 2 hours before cesarean delivery 1, 3
• Light meals: Permitted up to 6 hours before surgery 1, 3
• Carbohydrate loading: Consider giving preoperative carbohydrate drink to non-diabetic patients up to 2 hours before planned cesarean delivery 2, 3

Antimicrobial Prophylaxis and Skin Preparation

Antibiotic Administration (High Evidence, Strong Recommendation)

• Timing: Administer 30-60 minutes before skin incision 1
• Standard regimen: First-generation cephalosporin (weight-based cefazolin) for all patients 1
• Enhanced coverage: Add azithromycin 500mg IV for patients in labor or with ruptured membranes, which provides additional reduction in postoperative infections 1
• Dosing specifics: 2g IV for patients with obesity or weight ≥80kg; 1-2g IV for others 2

Skin Preparation (High Evidence, Strong Recommendation)

• Abdominal preparation: Chlorhexidine-alcohol is preferred over aqueous povidone-iodine solution 1, 2
• Vaginal preparation: Povidone-iodine solution should be considered for reduction of post-cesarean infections 1

Anesthetic Management

Anesthesia Selection (Low Evidence, Strong Recommendation)

• Regional anesthesia is the preferred method for cesarean delivery as part of enhanced recovery protocol 1, 3
• Regional anesthesia reduces the stress response to surgery, including hyperglycemic response, and avoids risks of general anesthesia 1

Preoperative Medications

• Antacids and H2 receptor antagonists: Recommended for aspiration prophylaxis 3
• Maternal sedation: NOT recommended 3
• Gabapentin: Can be considered to decrease postoperative pain scores with movement 2

Hemorrhage Prophylaxis

• Tranexamic acid: 1g in 10-20mL saline or 10mg/kg IV is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients 2

Venous Thromboembolism Prophylaxis

• Mechanical prophylaxis: Routine use of pneumatic compression stockings is recommended preoperatively and continued until the patient is ambulatory 2, 3
• Heparin: Should NOT be used routinely for VTE prophylaxis 3

Hypothermia Prevention (Low Evidence, Strong Recommendation)

Maternal Warming Measures

• Active warming: Forced air warming and intravenous fluid warming are recommended 1, 3
• Operating room temperature: Maintain at 21-25°C to support both maternal and neonatal normothermia 1
• Temperature monitoring: Appropriate patient monitoring is needed to apply warming devices and avoid hypothermia 1

Perioperative hypothermia occurs in 50-80% of patients undergoing spinal anesthesia and is associated with surgical site infection, myocardial ischemia, coagulopathy, and poor patient satisfaction 1

Fluid Management (Low-Moderate Evidence, Strong Recommendation)

• Perioperative euvolemia: Maintain appropriate fluid balance, as this is an important factor leading to improved maternal and neonatal outcomes 1, 3
• Avoid fluid overload, which increases risk of cardiovascular work, pulmonary edema, and can result in newborn weight loss 1

Patient Positioning and Operating Room Setup

• Left lateral tilt or manual displacement: Use to decrease hypotensive episodes; right lateral tilt is NOT recommended 2
• Noise control: Maintain levels that allow clear communication between teams 2
• Music: Can be used to improve patient outcomes 2

Urinary Catheter Management

• Indwelling catheter placement is NOT necessary for routine cesarean delivery 2

Surgical Field Preparation

• Draping: Use nonadhesive drapes 2
• Cell salvage: Effective for high-risk patients but NOT recommended for routine use 2

Supplemental Oxygen

• Maternal supplemental oxygen does NOT improve outcomes and is not routinely recommended 2, 3

Safety Protocols

• Surgical safety checklist: Including a timeout is recommended for all cesarean deliveries 2
• Neonatal resuscitation capacity: All settings performing cesarean delivery must have equipment, staffing, and skills for immediate neonatal resuscitation 1

Special Considerations for Group B Streptococcus

• GBS screening: Women expected to undergo cesarean delivery should undergo routine vaginal and rectal screening at 35-37 weeks gestation 1
• Intrapartum prophylaxis: NOT indicated for cesarean delivery performed before labor onset with intact membranes, regardless of GBS status 1
• However, screening is still necessary because labor or membrane rupture can occur before planned cesarean delivery 1

Optimization of Comorbidities

• Preoperative optimization: Address hypertension, diabetes mellitus, anemia, and smoking cessation when time permits 1
• Glucose control: For diabetic patients, schedule surgery early in the day with minimal fasting to reduce risk of dehydration, acidosis, and ketosis 1