What are the guidelines for managing a patient undergoing a cesarean section (CS), including preoperative evaluation, prophylactic measures, pain management, and post-operative care?

Cesarean Section Surgical Assist Note Guidelines

Preoperative Preparation (30-60 minutes before incision)

Administer prophylactic antibiotics within 60 minutes before skin incision—specifically a first-generation cephalosporin for all patients, with additional azithromycin for women in labor or with ruptured membranes. 1

Skin and Vaginal Preparation

• Cleanse the abdominal skin with chlorhexidine-alcohol solution rather than aqueous povidone-iodine 1, 2
• Prepare the vagina with povidone-iodine solution to reduce post-cesarean infections 1, 2
• Use electric clippers rather than razors for hair removal at the surgical site 3

Anesthetic Management

• Regional anesthesia (spinal or epidural) is the preferred method for cesarean delivery 1, 4
• Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anesthesia for postoperative pain control 5, 1, 6
• Administer H2 receptor antagonists and antacids preoperatively 7
• Allow clear fluids up to 2 hours before surgery and small meals within 6 hours 7

Intraoperative Management

Maternal Temperature Control

Implement active warming measures including forced-air warming devices, warmed intravenous fluids, and increased operating room temperature to prevent maternal hypothermia. 1, 4

Surgical Technique

• Use Joel-Cohen incision technique when possible for reduced postoperative pain 5, 1
• Perform blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 1
• Remove the placenta by spontaneous delivery with cord traction rather than manual extraction to reduce endometritis 2, 3
• Close the hysterotomy in 2 layers to reduce uterine rupture risk in subsequent pregnancies 1, 3
• Do not close the peritoneum—closure increases operative time without improving outcomes 1
• Reapproximate subcutaneous tissue if ≥2 cm thick to reduce seroma, hematoma, and wound disruption 1, 3
• Close skin with subcuticular suture in most cases 1

Fluid Management

• Maintain perioperative euvolemia through appropriate fluid administration 1, 4
• Use fluid preloading and intravenous ephedrine or phenylephrine to reduce hypotension and prevent nausea/vomiting 5

Antiemetic Prophylaxis

Use combination antiemetic regimens (5-HT3 antagonist combined with droperidol or dexamethasone) as they are significantly more effective than single agents. 5

• Administer single-dose intravenous dexamethasone after delivery for both analgesic and antiemetic effects 5, 1
• Consider tropisetron 2 mg and metoclopramide 20 mg for highly effective nausea/vomiting prevention 5

Neonatal Care at Delivery

• Delay cord clamping for at least 1 minute at term delivery 1, 4
• Delay cord clamping for at least 30 seconds at preterm delivery 1
• Avoid routine suctioning of the airway or gastric aspiration—use only for obstructive airway symptoms 1
• Provide routine neonatal supplementation with room air 1
• Maintain neonatal body temperature between 36.5°C and 37.5°C after birth 1, 4
• Ensure immediate neonatal resuscitation capacity is available 1

Postoperative Pain Management

Implement multimodal analgesia including regular paracetamol and NSAIDs with opioids reserved for rescue only. 5

Analgesic Regimen

• Continue paracetamol and NSAIDs regularly postoperatively (initiated after delivery) 5, 1, 4
• If intrathecal morphine was not administered, consider single-injection local anesthetic wound infiltration, continuous wound local anesthetic infusion, or fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 5, 1
• Apply abdominal binders for improved pain management 5, 1
• Consider transcutaneous electrical nerve stimulation as an analgesic adjunct 5, 1
• Minimize systemic opioid utilization and develop individualized post-discharge opioid prescribing 5, 1

Postoperative Care

Early Recovery Measures

• Resume regular diet within 2 hours after cesarean delivery 5, 4, 7
• Remove urinary catheter immediately after surgery if placed intraoperatively 5
• Encourage early mobilization after cesarean delivery 5, 4
• Consider chewing gum to enhance bowel recovery if early oral intake is delayed 5

Thromboembolism Prophylaxis

• Use pneumatic compression stockings to prevent thromboembolic disease 5, 7
• Do not use heparin routinely for venous thromboembolism prophylaxis after cesarean delivery 5, 7
• Institute appropriate prophylaxis for deep vein thrombosis in intermediate and high-risk patients 3

Glucose Management

• Maintain tight control of capillary blood glucose postoperatively 5, 7

Discharge Planning

• Provide standardized written discharge instructions 5

Critical Pitfalls to Avoid

Never administer antibiotics after cord clamping—evidence strongly supports pre-incision administration to decrease wound infections, despite historical concerns about fetal exposure. 1

• Do not omit basic analgesics (paracetamol/NSAIDs) when using intrathecal morphine, as this increases opioid requirements 6
• Avoid using razors for hair removal—use electric clippers instead 3
• Do not use aqueous povidone-iodine for abdominal skin preparation—chlorhexidine-alcohol is superior 1
• Do not manually extract the placenta—use spontaneous delivery with cord traction 2, 3
• Avoid single-layer uterine closure—two-layer closure reduces subsequent rupture risk 1, 3
• Do not close the peritoneum—it provides no benefit and increases operative time 1