What are the necessary preparations for a patient undergoing caesarean delivery?

Caesarean Delivery Preparations

All patients undergoing caesarean delivery must receive weight-based intravenous cefazolin (2g for patients ≥80kg or with obesity, 1-2g for others) within 60 minutes before skin incision, with adjunctive azithromycin 500mg IV added for patients in labor or with ruptured membranes, as this reduces postoperative infections including endometritis from 8.3% to 4.3%. 1, 2

Preoperative Antimicrobial Prophylaxis

• Antibiotic timing is critical: Administer 30-60 minutes before skin incision, not after cord clamping, as preoperative administration significantly reduces wound infections and endometritis 1, 2, 3

• Enhanced coverage for high-risk patients: Women in labor or with ruptured membranes require azithromycin 500mg IV in addition to cefazolin, providing additional reduction in postoperative infections (RR 0.45,95% CI 0.25-0.81) 1, 2

• Weight-based dosing: Use 2g cefazolin for patients weighing ≥80kg or with obesity; 1-2g for others 2, 3

Skin and Vaginal Preparation

• Chlorhexidine-alcohol is strongly preferred over aqueous povidone-iodine for abdominal skin cleansing, despite some mixed evidence, based on the broader surgical literature 1, 2, 3

• Vaginal preparation with povidone-iodine solution should be performed in all patients, particularly those in labor or with ruptured membranes, to reduce endometritis risk 1, 2, 3

• Hair removal: If necessary, use electric clippers or depilatory creams—never razors, which increase infection risk 3, 4

Anesthetic Management

• Regional anesthesia is mandatory as the preferred method, providing superior pain control, organ function, mobility, and postoperative recovery compared to general anesthesia 1, 2

• Intrathecal morphine provides superior postoperative analgesia, though side effects (nausea, vomiting, pruritus) increase with dosage 1

• Combined spinal-epidural may allow more rapid motor recovery than spinal alone, with the epidural catheter providing capability to extend inadequate blocks 1

Prevention of Hypothermia

• Active warming is essential: Implement forced air warming, intravenous fluid warming, and maintain operating room temperature at 21-25°C 1, 2, 3

• Monitor temperature appropriately: Core or axillary temperature monitoring (with sensor over axillary artery and arms adducted) should guide warming interventions 1

• Hypothermia consequences: Perioperative hypothermia occurs in 50-80% of patients with spinal anesthesia and causes surgical site infection, myocardial ischemia, coagulopathy, prolonged hospitalization, and adverse neonatal effects (temperature, umbilical pH, Apgar scores) 1

Preoperative Fasting and Nutrition

• Clear liquids permitted up to 2 hours before surgery 2, 3, 5

• Light meals permitted up to 6 hours before surgery 2, 3, 5

• Consider preoperative carbohydrate drink (up to 2 hours before) for non-diabetic patients undergoing planned caesarean 3

Patient Positioning and Hemodynamics

• Left lateral tilt or manual displacement of the uterus prevents aortocaval compression and reduces hypotensive episodes; manual displacers are superior to left lateral tilt alone 2, 3

• Never use right lateral tilt, as it does not prevent hypotension 3

Additional Preoperative Measures

• Venous thromboembolism prophylaxis: Apply mechanical prophylaxis (pneumatic compression stockings) preoperatively and continue until ambulatory 3, 5

• Tranexamic acid: Administer 1g IV (in 10-20mL saline) or 10mg/kg for patients at high risk of postpartum hemorrhage; consider for all patients 3

• Preoperative gabapentin: Consider to decrease postoperative pain scores with movement 3

• No bowel preparation or enema is recommended 3, 5

• Surgical safety checklist and timeout must be performed for all caesarean deliveries 3

Neonatal Resuscitation Capacity

• Immediate resuscitation capability is mandatory in all settings performing caesarean delivery, with appropriate equipment, staffing, and skills 1, 2

• Delayed cord clamping: Clamp at ≥1 minute for term deliveries and ≥30 seconds for preterm deliveries 1

• Avoid routine suctioning of airway or gastric aspiration unless obstructive symptoms present 1

Critical Pitfalls to Avoid

• Never administer antibiotics after cord clamping—this outdated practice significantly increases infection rates 1, 3, 4

• Never use razors for hair removal—only clippers or depilatory creams 3, 4

• Never skip vaginal preparation—this simple intervention substantially reduces endometritis 1, 3

• Never allow maternal hypothermia—actively warm all patients as hypothermia causes multiple maternal and neonatal complications 1, 2

• Never proceed without documented resuscitation capability—this is a non-negotiable safety requirement 1, 2