What are the steps of a cesarean section (C-section) for a pregnant woman with a term gestation and no significant medical history?

Steps of Cesarean Section

For a routine cesarean delivery at term, perform a Joel-Cohen transverse incision, use blunt expansion of the lower uterine segment hysterotomy, deliver the infant with delayed cord clamping for at least 1 minute, close the uterus in 2 layers, leave the peritoneum open, and close skin with subcuticular sutures. 1

Pre-operative Preparation (30-60 minutes before incision)

Antibiotic Prophylaxis

• Administer intravenous first-generation cephalosporin within 60 minutes before skin incision—not after cord clamping as was previously practiced 1
• Add azithromycin if the woman is in labor or has ruptured membranes 1

Skin and Vaginal Preparation

• Cleanse the abdominal skin with chlorhexidine-alcohol solution 1
• Perform vaginal preparation with povidone-iodine solution to reduce postcesarean infections 1

Anesthetic Management

• Use regional anesthesia (spinal or epidural) as the preferred method 1
• Administer pre-operative oral paracetamol 1
• Give intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) for optimal postoperative analgesia 1

Patient Positioning

• Position women after 20 weeks gestation with left uterine displacement to prevent aortocaval compression 2

Intraoperative Steps

Abdominal Entry

• Make a Joel-Cohen incision—this is a Grade A recommendation for reduced pain and improved outcomes 1
• The Joel-Cohen technique involves a straight transverse incision 3 cm below the line joining the anterior superior iliac spines 1

Uterine Incision

• Create a transverse incision in the lower uterine segment 1
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 1
• If access to the lower segment is difficult (preterm labor, dense adhesions, placenta previa/accreta), a vertical hysterotomy (classical cesarean section) may be necessary, though this carries higher risks 3

Fetal Delivery

• Deliver the infant through the hysterotomy 1
• Delay cord clamping for at least 1 minute at term delivery (at least 30 seconds for preterm infants) 1

Intraoperative Medications

• Administer intravenous paracetamol if not given pre-operatively 1
• Give intravenous non-steroidal anti-inflammatory drugs (NSAIDs) 1
• Administer intravenous dexamethasone for pain control and anti-emetic prophylaxis (use caution in women with glucose intolerance) 1

Temperature Management

• Apply forced air warming to prevent maternal hypothermia 1
• Warm intravenous fluids 1
• Increase operating room temperature appropriately 1

Fluid Management

• Maintain perioperative and intraoperative euvolemia for improved maternal and neonatal outcomes 1

Closure Technique

Uterine Closure

• Close the hysterotomy in 2 layers—this is associated with a lower rate of uterine rupture in subsequent pregnancies compared to single-layer closure 1
• The uterus can be repaired either intra-abdominally or extra-abdominally, though the debate continues 4

Peritoneal Management

• Do not close the peritoneum—this critical step is not associated with improved outcomes and only increases operative time 1
• Nonclosure of the visceral peritoneum confers significant benefit 4

Subcutaneous Tissue

• In women with ≥2 cm of subcutaneous tissue, reapproximate that tissue layer to reduce wound complications 1, 5

Skin Closure

• Close skin with subcuticular suture in most cases 1
• Evidence shows subcuticular sutures reduce wound separation compared to staples removed at 4 days 1

Regional Analgesia Options

• Consider local anesthetic wound infiltration (single-shot or continuous infusion) 1
• Transversus abdominis plane (TAP) blocks or quadratus lumborum blocks may be used 1
• These blocks provide minimal additional benefit when combined with intrathecal morphine 1

Critical Pitfalls to Avoid

• Never delay antibiotic administration until after cord clamping—this outdated practice increases infection risk 1
• Avoid closing the peritoneum—this increases operative time without benefit 1
• Do not use staples for skin closure if they will be removed at 4 days—subcuticular sutures reduce wound complications 1
• Avoid inadequate uterine incisions—operative complications including injury to the fetus and lacerations of the uterus and vagina result from inadequate uterine incisions 6
• Do not create a bladder flap routinely—recent studies challenge this accepted practice as it may not represent best practice 4
• Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine/dexmedetomidine—limited evidence and concerning side effects 1

Special Considerations

Classical Cesarean Section

• When a vertical hysterotomy is necessary, recognize that uterine closure is technically more difficult 3
• A speedy and skillful technique is mandatory to decrease risks of hemorrhage and adhesion 3
• Cases of prior classical cesarean section are absolutely contraindicated for trial of labor after cesarean section due to high risk of uterine rupture 3

High-Risk Populations

• In women with obesity (BMI ≥30), ensure active management of the third stage of labor due to increased risk of postpartum hemorrhage 5
• Alert operating room staff when a woman's weight exceeds 120 kg to ensure adequate staffing and equipment availability 5
• Apply mechanical thromboprophylaxis using pneumatic compression devices before cesarean section when possible 5