What are the indications, pre‑operative assessment, intra‑operative steps, and postoperative care for a caesarean section?

Caesarean Section: Evidence-Based Approach

For caesarean delivery, implement a comprehensive Enhanced Recovery After Surgery (ERAS) protocol that prioritizes infection prevention, regional anesthesia, and evidence-based surgical techniques to minimize maternal morbidity and optimize both maternal and neonatal outcomes. 1

Indications

While the evidence provided focuses primarily on perioperative management rather than indications, caesarean section should be performed when clearly advantageous for maternal or fetal outcomes. Medical indications are present in less than 10% of cases, yet rates have risen substantially due to changed risk profiles, risk avoidance tendencies, and maternal request 2. The decision must weigh increased risks to both mother and child against potential benefits.

Pre-operative Assessment and Preparation

Antimicrobial Prophylaxis (Critical for Infection Prevention)

Administer IV antibiotics within 60 minutes before skin incision—this is a high-evidence, strong recommendation that directly reduces postoperative infections and maternal morbidity. 1

• All women: First-generation cephalosporin (weight-based cefazolin: 2g IV for obesity or weight ≥80 kg; 1-2g for others) 3
• Women in labor OR with ruptured membranes: Add azithromycin 500 mg IV—this confers additional significant reduction in postoperative infections 1
• Timing is critical: 30-60 minutes before incision, NOT after cord clamping (historical practice now abandoned due to clear infection reduction data) 1

Skin Preparation

Use chlorhexidine-alcohol for abdominal skin preparation—this is preferred over povidone-iodine based on broader surgical evidence. 1

Perform vaginal preparation with povidone-iodine solution in women in labor or with ruptured membranes—reduces endometritis from 8.3% to 4.3% (RR 0.45) 1

Fasting and Carbohydrate Loading

• Clear liquids permitted up to 2 hours before surgery 4, 3
• Light meal up to 6 hours before surgery 4, 3
• Consider preoperative carbohydrate drink (up to 2 hours before) in non-diabetic patients to reduce insulin resistance 4, 3

Additional Preoperative Measures

• Shower with soap or antiseptic the night before 3
• Hair removal: Only if necessary—use clippers or depilatory cream, NEVER shaving (increases infection risk) 3
• NO bowel preparation (not recommended) 4
• NO routine maternal sedation 4
• Antacids/H2 receptor antagonists: Recommended 4
• Tranexamic acid 1g IV (or 10 mg/kg): Recommended for high-risk hemorrhage patients, consider for all 3
• Mechanical VTE prophylaxis: Apply preoperatively, continue until ambulatory 3

Intra-operative Management

Anesthesia

Regional anesthesia (spinal or epidural) is the preferred method—this is a strong recommendation despite low-quality evidence, based on improved pain control, organ function, and recovery. 1

• Spinal anesthesia is the technique of choice for most women without epidural catheter in situ 5
• For women with labor epidural: top-up with levobupivacaine 0.5% 5
• If epidural fails to achieve bilateral T5-S5 anesthesia: use combined spinal-epidural with small intrathecal dose 5
• General anesthesia: Do NOT reduce induction/maintenance drug doses (outdated concern about fetal harm) 5

Temperature Management

Actively prevent maternal hypothermia—this occurs in 50-80% of patients with spinal anesthesia and affects outcomes. 1

• Forced air warming devices
• Warmed IV fluids
• Increase operating room temperature
• Monitor temperature continuously 1

Surgical Technique

Use blunt expansion of transverse uterine hysterotomy—reduces surgical blood loss. 1

Close hysterotomy in 2 layers—associated with lower uterine rupture rates in subsequent pregnancies. 1

Do NOT close the peritoneum—no improved outcomes, only increases operative time. 1

Reapproximate subcutaneous tissue if ≥2 cm thick. 1

Use subcuticular suture for skin closure (not staples)—reduces wound separation. 1

Fluid Management

Maintain perioperative euvolemia—important for both maternal and neonatal outcomes. 1

Neonatal Care at Delivery

Delay cord clamping for at least 1 minute at term (30 seconds for preterm)—this is a moderate-evidence, strong recommendation. 1

• Maintain neonatal temperature 36.5-37.5°C 1
• AVOID routine airway suctioning or gastric aspiration—only for obstructive symptoms 1
• Use room air for resuscitation, NOT supplemental oxygen—oxygen may cause harm 1
• Immediate resuscitation capability is mandatory 1

Postoperative Care

Pain Management (Multimodal Approach)

Use scheduled acetaminophen and NSAIDs as the foundation—this is opioid-sparing and reduces side effects. 6, 7

• Acetaminophen 650 mg PO every 6 hours 7
• Ketorolac 30 mg IV every 6 hours for 4 doses, then ibuprofen 600 mg PO every 6 hours 7
• Short-acting opioids ONLY for breakthrough pain (individualize based on inpatient requirements) 7
• Consider gabapentin preoperatively to decrease postoperative pain with movement 3

Antibiotic Continuation

Do NOT routinely give multi-dose prophylactic antibiotics postoperatively. 7

Additional doses indicated only for:

• Obesity without preoperative azithromycin
• Surgery ≥4 hours since prophylactic dose
• Blood loss >1500 mL
• Intra-amniotic infection 7

Early Recovery Measures

Resume regular diet within 2 hours after surgery—high-evidence, strong recommendation that improves satisfaction, reduces length of stay, and accelerates bowel function return. 6, 7

Remove indwelling urinary catheter immediately postoperatively (if placed for scheduled CS) 6, 7

Encourage early ambulation starting 4 hours postoperatively—incentivize with pedometer 7

Consider chewing gum to aid bowel function return 6, 7

Antiemetic Prophylaxis

Use 5HT3 antagonists PLUS either dopamine antagonist OR corticosteroid 7

VTE Prophylaxis

• Continue mechanical prophylaxis until ambulatory 7
• Chemoprophylaxis reserved for patients with additional risk factors 7
• Do NOT routinely use heparin 4

Glucose Management

Maintain tight capillary glucose control in diabetic patients—reduces surgical site infections 6

• Measure CBG every 30 minutes during general anesthesia until fully conscious 6
• Schedule diabetic patients early in day with minimal fasting 6
• Insulin requirements fall rapidly after delivery—check CBG if receiving insulin 6

Wound Care

Leave dressing in place for 48 hours (limited evidence) 7

Discharge Planning

Discharge at 24-28 hours for low-risk patients IF close (1-2 day) neonatal follow-up available (due to jaundice risk); otherwise 48-72 hours 7

Provide standardized written discharge instructions including:

• Continue multimodal pain control (acetaminophen + ibuprofen) 7
• Optimal interpregnancy interval: 18-23 months 7
• Encourage exclusive breastfeeding for ≥6 months 7
• Resume physical activity quickly 7
• Vaginal intercourse as tolerated 7
• Contraception options (immediate postpartum IUD, intraoperative salpingectomy, or LARC) 7

Common Pitfalls

• Giving antibiotics after cord clamping: Historical practice now proven inferior—give 30-60 minutes BEFORE incision 1
• Using staples for skin closure: Increases wound separation compared to subcuticular suture 1
• Closing the peritoneum: Wastes time without benefit 1
• Delaying oral intake: Early feeding (within 2 hours) is safe and beneficial 6, 7
• Over-prescribing opioids: Multimodal non-opioid analgesia should be the foundation 7
• Routine multi-dose antibiotics postoperatively: Not indicated unless specific risk factors present 7