What pre‑operative rounding questions should be asked of a patient scheduled for a cesarean delivery?

Pre-Operative Rounding Questions for Cesarean Section

Before proceeding to the operating room, systematically verify antibiotic timing, NPO status, anesthesia readiness, and high-risk factors that require specialized preparation or multidisciplinary coordination.

Essential Pre-Operative Verification Questions

Antibiotic Prophylaxis Timing

• Confirm weight-based cefazolin (1-2g for non-obese patients, 2g for obese or ≥80kg) will be administered within 60 minutes before skin incision 1, 2
• Ask specifically: "Is the patient in labor or are membranes ruptured?" If yes, azithromycin 500mg IV must be added to reduce postoperative infections 1, 2
• Verify antibiotic allergies and alternative regimens if needed 1

NPO Status and Aspiration Risk

• Clear liquids permitted up to 2 hours before surgery; light meals up to 6 hours before 1, 3
• Document exact timing of last oral intake 3
• Consider preoperative carbohydrate drink for non-diabetic patients up to 2 hours before planned cesarean 3

Anesthesia Planning

• Confirm regional anesthesia is planned (preferred method to reduce stress response and avoid general anesthesia risks) 1, 2
• Identify any contraindications to regional anesthesia requiring general anesthesia 1
• Verify anesthesia team awareness of patient comorbidities 1

High-Risk Scenario Identification

Placenta Accreta Spectrum Screening

• Ask: "Is there known or suspected placenta accreta, previa, or abnormal placentation?" 4
• If yes, verify:
  • Multidisciplinary team coordination (maternal-fetal medicine, gynecologic oncology, anesthesiology, neonatology) is confirmed 4
  • Blood bank notification completed with cross-match and massive transfusion protocol readiness 4
  • Delivery timing planned for 34 0/7 to 35 6/7 weeks if stable 4
  • Expert pelvic surgeons available 4

Prior Cesarean Deliveries

• Document exact number of prior cesarean sections (risk of placenta accreta increases from 12.9/10,000 after one CS to 78.3/10,000 after three CS) 5
• Verify inter-delivery interval (interval <18 months significantly increases rupture risk) 5
• Ask about type of prior uterine incision (classic vertical scar carries substantially higher rupture risk) 5

Comorbidity Optimization Status

• Diabetes control: Verify glucose levels to prevent dehydration, acidosis, and ketosis 1
• Anemia status: Check most recent hemoglobin (iron deficiency should have been addressed with oral/IV replacement or erythropoietin) 4
• Hypertension control: Confirm blood pressure management 1
• Smoking status: Document cessation efforts 1

Infection Prevention Verification

Skin Preparation Supplies

• Confirm chlorhexidine-alcohol available for abdominal preparation (preferred over povidone-iodine) 1, 2, 3
• Verify povidone-iodine solution available for vaginal preparation 1, 2, 3
• Confirm hair removal (if needed) was performed with clippers or depilatory cream, NOT shaving 3

Group B Streptococcus Status

• Ask: "What is the GBS status?" (routine screening at 35-37 weeks recommended) 1
• Note: Intrapartum prophylaxis NOT indicated for cesarean before labor onset with intact membranes, regardless of GBS status 1

Hemorrhage Risk Assessment

Tranexamic Acid Consideration

• Identify high-risk hemorrhage patients: placenta previa, accreta, multiple prior cesareans, known coagulopathy 3
• Tranexamic acid 1g in 10-20mL saline (or 10mg/kg IV) should be given prophylactically for high-risk patients and can be considered for all patients 3

VTE Prophylaxis

• Confirm mechanical VTE prophylaxis (sequential compression devices) will be applied preoperatively and continued until ambulatory 3
• Assess additional VTE risk factors requiring pharmacologic prophylaxis 3

Maternal Comfort and Safety Measures

Hypothermia Prevention

• Verify forced air warming device, IV fluid warmer, and operating room temperature 21-25°C 1, 2
• Active warming prevents maternal hypothermia and supports neonatal normothermia 1, 2

Pain Management

• Consider preoperative gabapentin to decrease postoperative pain scores with movement 3
• Confirm effective pain management availability (cesarean should not be performed due to unavailable pain management for labor) 6

Patient Positioning

• Plan for left lateral tilt or manual uterine displacement (decreases hypotensive episodes; right lateral tilt NOT recommended) 3
• Maintain left uterine displacement to prevent aortocaval compression 5

Neonatal Readiness

Gestational Age Verification

• Confirm gestational age ≥39 weeks for scheduled cesarean without medical indication 6
• If 34-37 weeks, verify antenatal corticosteroids were administered for lung maturation 4
• No amniocentesis needed at 34-37 weeks (pulmonary maturity data don't change delivery recommendations) 4

Resuscitation Preparedness

• Verify neonatal resuscitation capacity present: equipment, staffing, and skills for immediate resuscitation 1
• Confirm neonatology team awareness for preterm or high-risk deliveries 4

Surgical Safety Protocol

Timeout and Checklist

• Confirm surgical safety checklist will be performed including timeout 3
• Verify correct patient, procedure, site, and consent 3

Urinary Catheter Decision

• Indwelling urinary catheter placement is NOT necessary for routine cesarean 3
• Consider only for specific indications (prolonged surgery, complex cases) 3

Common Pitfalls to Avoid

• Never proceed without confirming antibiotic timing (must be within 60 minutes before incision, not at cord clamp) 1, 2
• Never overlook azithromycin addition for patients in labor or with ruptured membranes 1, 2
• Never schedule elective cesarean <39 weeks without medical indication 6
• Never use misoprostol in patients with prior cesarean (13% rupture rate in third trimester) 5
• Never delay surgical preparation for suspected placenta accreta cases (requires specialized team and blood products) 4