Continuing Education Activity

Cesarean delivery, also known as a C-section, is a surgical procedure performed to deliver a baby through incisions made in the mother's abdomen and uterus. The operation is typically performed when a vaginal birth poses risks to the mother or baby or when complications arise during labor. Common reasons for a cesarean section include fetal distress, abnormal positioning of the baby, placental issues, or a previous cesarean delivery. While cesarean deliveries are generally considered safe, they are major surgeries and carry risks such as infection, bleeding, and longer recovery times compared to vaginal births. Nonetheless, the procedures can be life-saving interventions in certain medical situations. The cesarean section is the most common surgery performed in the United States, with more than a million cesarean deliveries performed every year. Decisions made during a cesarean section can affect women and their families for the entirety of their lives.

This activity provides clinicians with an in-depth understanding of current practices, guidelines, and emerging trends in cesarean delivery. A range of topics are covered, including the indications for cesarean section, preoperative and postoperative care, surgical techniques, and management of potential complications. Participants improve their clinical decision-making, expand their knowledge of new guidelines, and ultimately contribute to better patient care and safety. The activity also highlights how collaborating with the interprofessional care team can impact the procedure and, thus, the health of women and their newborns.

Objectives:

• Identify appropriate indications for cesarean section to ensure evidence-based decision-making.
• Apply the latest research and guidelines to optimize care before, during, and after cesarean delivery.
• Assess common complications associated with cesarean sections to reduce risks and improve recovery.
• Evaluate interprofessional team strategies for improving care coordination and communication to improve the outcomes of women undergoing cesarean sections.

Introduction

Cesarean section involves a fetal delivery through an open abdominal incision (laparotomy) and an incision in the uterus (hysterotomy). The first documented cesarean operation occurred in AD 1020, and the surgery has evolved tremendously since.[1] The procedure is now the most common operation performed in the United States, with more than 1 million women undergoing cesarean delivery annually.

The cesarean delivery rate rose from 5% in 1970 to 31.9% in 2016.[2] This sharp increase can be attributed to various factors, including changes in maternal age, medical advancements allowing more complicated pregnancies to proceed, and evolving obstetric practices. Despite ongoing efforts to reduce the cesarean rate through initiatives like promoting vaginal births after cesarean and encouraging natural labor when safe, experts predict that a significant decrease is unlikely to occur for at least another decade or more.[3] While the procedure confers risks of both immediate and long-term complications, for some women, cesarean delivery can be the safest or even the only way to deliver a healthy newborn.

Anatomy and Physiology

To perform a cesarean delivery, the surgeon must carefully navigate through multiple anatomical layers to reach the fetus. The procedure begins with an incision in the skin, followed by the subcutaneous tissue. Next, the fascia covering the rectus abdominis muscles is exposed. This fascia typically has two layers: one from the aponeurosis of the external oblique muscle, and a second fused layer containing the aponeuroses of the transverse abdominis and internal oblique muscles. After the rectus muscles, which run vertically, are separated, the surgeon enters the abdominal cavity by incising the parietal peritoneum. In a gravid woman, the uterus is often encountered immediately upon entry into the abdomen, unlike in a nongravid woman. If the patient has an adhesive disease from prior surgeries, the surgeon may encounter adhesions involving structures such as the omentum, bowel, anterior abdominal wall, bladder, and anterior aspect of the uterus.

Upon identifying the uterus, the surgeon can locate the vesicouterine peritoneum, or vesicouterine serosa, that connects the bladder and the uterus. If the surgeon desires to make a bladder flap, the vesicouterine peritoneum must be incised. In a patient with prior cesarean sections, the bladder may become difficult to separate from the uterus.

The uterus consists of the serosal outer layer (perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). All 3 layers are incised to make the uterine incision or hysterotomy. The uterine vessels run along with the lateral aspects of the uterus bilaterally, therefore care must be taken to avoid damaging these blood vessels when the uterine incision is either made or extended. The uterine arteries branch from the anterior division of the internal iliac artery. The blood flow through these arteries is 8 times faster during pregnancy, with a unilateral flow of more than 300 mL/min at 36 weeks gestation.[4] The uterine arteries cross the ureters anteriorly and enter the uterus at the cardinal ligament. The uterine arteries anastomose in the broad ligament with the ovarian arteries, which arise from the abdominal aorta. 

Depending on the status of the patient’s amniotic membranes (ruptured or intact), the surgeon may encounter the amniotic sac upon incision of the uterus. The amniotic sac consists of 2 layers, the chorion and the amnion, which fuse early in pregnancy. If present, the amniotic sac would be the last layer between the surgeon and the fetus. The fetus is delivered at this point, achieving the primary goal of the cesarean section.

The gravid uterus often obscures the remainder of the reproductive anatomy. However, after delivery of the fetus, other structures may become visible, which is particularly the case if the surgeon exteriorizes the uterus for repair. The surgeon may inspect the fallopian tubes and ovaries. A tubal ligation is performed if the patient has previously expressed the desire and has given informed consent for this form of permanent contraception. The broad ligament is also identifiable. This structure consists of 2 leaves of peritoneum and attaches the uterus to the pelvic sidewalls. The medial leaf of the broad ligament, if opened, may reveal the coursing ureter. The cervix, located at the lower portion of the uterus, is not routinely visible, nor is the vagina.

Indications

There are various reasons why a fetus cannot, or should not, be delivered vaginally.[5][6] Some of these indications are inflexible, as a vaginal birth would be dangerous in certain clinical scenarios. For example, a cesarean delivery is often the recommended procedure if the patient has had a prior classical cesarean section or previous uterine rupture. However, due to the potential complications of cesarean delivery, much attention has been paid to ways to reduce the cesarean rate.

Decreasing the number of first-time cesareans has been emphasized, as many women who have 1 cesarean delivery will ultimately have the remainder of their children via cesarean section. The patient may choose another cesarean for various reasons or may not be a candidate for a subsequent vaginal birth. For example, if a patient has an unfavorable cervix at term, cervical ripening with medications such as misoprostol is not recommended due to an increased risk of uterine rupture. In the 2011 article, Safe Prevention of the Primary Cesarean Delivery, authors addressed the most commonly documented indications for first-time cesarean deliveries, including labor dystocia, abnormal fetal heart rate pattern, malpresentation of the fetus, multiple gestations, and suspected fetal macrosomia.[7]

Maternal Indications for Cesarean Section

• Prior cesarean delivery
• Maternal request
• Pelvic deformity or cephalopelvic disproportion
• Previous perineal trauma
• Prior pelvic or anal/rectal reconstructive surgery
• Herpes simplex or human immunodeficiency virus infection
• Cardiac or pulmonary disease
• Cerebral aneurysm or arteriovenous malformation
• Pathology requiring concurrent intraabdominal surgery
• Perimortem cesarean [5][6]

Uterine/Anatomic Indications for Cesarean Section

• Abnormal placentation (eg, placenta previa, placenta accreta)
• Placental abruption
• Prior classical hysterotomy
• Prior full-thickness myomectomy
• History of uterine incision dehiscence
• Invasive cervical cancer
• Prior trachelectomy
• Obstructive mass in the genital tract
• Permanent cerclage [5][6]

Fetal Indications for Cesarean Section

• Nonreassuring fetal status (eg, abnormal umbilical cord on Doppler study) or abnormal fetal heart tracing
• Umbilical cord prolapse
• Failed operative vaginal delivery
• Malpresentation
• Macrosomia
• Congenital anomaly
• Thrombocytopenia
• Prior neonatal birth trauma [5][6]

A 2007 study investigated the level of additional fetal risk a patient or her caregiver considered to be acceptable to achieve a vaginal delivery and to avoid a cesarean section.[8] The authors concluded that both the pregnant patient and their caregivers had a low tolerance for fetal risk. Understandably, a gravid woman has high expectations for the outcome of her delivery; however, the goal of reducing cesarean rates may be difficult to achieve, considering this hesitance to expose the fetus to risk.

Contraindications

Cesarean section has no true medical contraindications. A cesarean delivery is an option if the pregnant patient or fetus is deceased or dying. While there are ideal conditions for cesarean section, such as the availability of anesthesia, antibiotics, and appropriate equipment, the absence of these is not a contraindication when the clinical scenario dictates.

Ethically, a cesarean is contraindicated if the patient refuses. Adequate education and counseling are crucial for informed consent; however, if the patient does not consent to an operation, ultimately, it is their right as an autonomous patient to refuse this mode of delivery.

There are several clinical scenarios in which a cesarean delivery may not be the preferred option. These instances can be considered relative contraindications. For example, a patient may have severe coagulopathy, which makes surgery extremely dangerous. In that case, vaginal delivery may be preferable. Alternatively, a patient with an extensive history of abdominal surgery may also be a poor surgical candidate. In the event of fetal demise, performing a cesarean section exposes the patient to the risks of a cesarean delivery without any fetal benefit; the same considerations apply if the fetus has severe anomalies that are incompatible with life.

Equipment

The equipment required for a cesarean delivery varies based on the clinical scenario.[9] At the most basic level, the only item necessary is a cutting instrument. In an emergency, a clinician could theoretically perform a perimortem cesarean delivery on a patient after a motor vehicle crash with a sharp piece of glass. Fortunately, such emergency scenarios are exceedingly rare. Various consumable and reusable items are used to make a cesarean section safer for the clinician, the pregnant patient, and the fetus. Again, the clinical scenario dictates the equipment used.

The surgical suite should have a surgical bed or table, which can move up and down based on the clinician’s needs. Associated with the surgical table are the rests for the patient’s arms, a safety strap or belt to ensure the patient does not fall off the table, and some wedge (or a rolled blanket) to achieve a left lateral tilt of the gravid patient. Surgical step stools should be available for the clinician and assistant.

A blanket warmer is often present in the operating room suite. This device provides warming for both the patient and the neonate. An indwelling catheter is typically placed in the patient’s bladder before the surgery. The operating room should also have overhead lighting to adequately illuminate the surgical field. Consumables commonly utilized during surgery include sutures, gloves, gowns, wound dressings, and hemostatic agents.

Once the patient is on the surgical table, a surgical drape maintains the sterile surgical field. The drape can either be fenestrated or not fenestrated around the patient’s abdomen and usually contains lateral pouches to catch amniotic or other fluids. The drape is typically secured to 2 poles on either side of the patient’s shoulders, obscuring the patient’s view of the surgical field. Clear drapes are also available, allowing the patient to watch the surgery and subsequent infant delivery if desired. Many hospitals may have a standardized surgical pack specific to cesarean delivery, containing the necessary drapes. The pack may also include surgical towels, a bulb suction, umbilical cord clamps, suction tubing, or other consumables specific to a cesarean section.

The anesthesia equipment, which includes monitors for patient vital signs, organizational cabinets, medications for achieving adequate anesthesia, and airway equipment, is at the head of the surgical table. Although cesarean deliveries usually take place with a regional anesthetic, general anesthesia can be necessary. Therefore, all equipment needed for obtaining and maintaining a patient’s airway should be readily available.

Most hospitals have a standardized surgical tray specifically for cesarean sections. This tray contains the surgical instruments traditionally used during the procedure and may vary by region or hospital. This tray may include several kinds of scissors (bandage, Metzenbaum, straight and curved Mayo), several kinds of clamps (Kelly, Kocher, Allis, Babcock), ring forceps, several kinds of tissue forceps (Adson, Russian, Ferris-Smith, smooth), retractors (bladder blade, Army-Navy, Richardson), knife handles, needle drivers, suction (Yankauer or Poole), or other instruments.

The availability of a standardized surgical pack and cesarean instrument tray can be beneficial. If an emergency cesarean is needed, this will mitigate the time-consuming need to gather appropriate equipment. In addition to standard instrument trays for the cesarean section, a hysterectomy instrument tray should also be available. A peripartum hysterectomy is relatively rare, but it is becoming more common. Having the appropriate instruments readily accessible can save precious time in an emergency.

Personnel

A cesarean section requires a skilled and coordinated medical team to ensure the safety and well-being of both the pregnant patient and the baby. The personnel involved play critical roles in managing the procedure, from preoperative preparation to postoperative care.

The primary personnel for a cesarean section typically include:

• Surgeon
• Surgical assistant
• Anesthesiologist or anesthetist
• Surgical technician or operating room nurse
• Circulating or operating room nurse
• Dedicated clinician to care for the neonate

Before any surgery is possible, the patient should have analgesia. Except for rare emergencies, the anesthesia team will provide the analgesia. An anesthesiologist or a nurse anesthetist may be on this team. In some institutions, obstetric anesthesia is the responsibility of a dedicated obstetric team. In others, anesthesia clinicians care for patients in all surgical suites, including the main operating room and the labor floor. In addition to analgesia, the anesthesiologist or anesthetist are crucial in managing the patient's airway and monitoring vital signs, surgical blood loss, and urine output. If additional medications or blood products are administered or blood needs to be drawn for laboratory testing, the anesthesia staff often performs these tasks.

The primary surgeon during a cesarean section may vary by hospital and region. In many hospitals, the primary surgeon is an obstetrician/gynecologist. A general surgeon may perform cesarean sections in other hospitals, especially in rural settings. Family clinicians who practice obstetrics may also perform cesarean sections.

The surgical assistant also varies. They may be another clinician, such as a practice partner or an obstetric hospitalist. The assistant may be a trained nurse, certified nurse-midwife, resident physician, or fellow. The surgical technician's role is traditionally to provide the surgeon with the necessary instruments, but they may assist the surgeon if necessary.

The circulating nurse is a nonsterile member of the team. As such, they can retrieve additional equipment or supplies that may be needed. They can chart or document as indicated and play a role in ensuring the patient's safety. The circulating nurse often works with the surgical technician to ensure that the counts of surgical instruments, needles, and sponges are correct.

A nurse, advanced clinician, or physician can assume care of the neonate after delivery. They perform the initial resuscitation of the newborn, including assessment and warming. If the neonate is expected to be significantly preterm or needs specialized care (congenital disabilities, drug exposures, etc), additional staff to care for the newborn is often required. This care may include advanced clinicians or physicians from the neonatal intensive care unit. In some practice settings or scenarios, the primary surgeon or anesthesiologist may be called upon to assist in caring for the newborn.[10]

Preparation

According to enhanced recovery protocols, prenatal care should include educating patients and their partners about the possibility of cesarean delivery. The patient should receive information about what to expect before, during, and after the procedure. If a cesarean delivery is anticipated due to maternal or fetal indications, any maternal comorbidities such as anemia, diabetes, hypertension, or obesity should be optimized preoperatively if possible.[11]

Aspiration with subsequent pneumonitis is a risk with cesarean delivery. Preoperative antacids (sodium citrate) and a histamine H2 antagonist can be administered to prevent low gastric pH. Traditionally, a patient is asked to be "nil per os," or NPO after midnight. In a stable patient with an unscheduled cesarean, it is common to ask the patient to fast for 6 hours. Most recently, enhanced recovery protocols have recommended that patients be encouraged to drink clear liquids until 2 hours before the scheduled surgery, and solid food is prohibited for 6 hours prior. Additionally, carbohydrate fluid supplementation may be offered to patients aho are not diabetic up to 2 hours before surgery, which may improve patient outcomes. Oral or mechanical bowel preparation is not recommended. In the case of emergencies, NPO status may be superseded by urgent fetal or maternal indications.

Preoperative gabapentin has been found to improve pain control after cesarean delivery. Preoperative sedation, however, should not be administered due to the risk of impaired psychomotor function after delivery, as well as fetal risks, including problems with thermogenesis, low Apgar scores, and "floppy baby syndrome."[11]

As with any surgery, cesarean section carries a risk of infection. The incision is considered a clean-contaminated surgical wound due to the contiguous nature of the uterus, cervix, and vagina. Cesarean section is the most critical risk factor for a woman developing an infection in the postpartum period. Women who have a cesarean delivery are at 20 times greater risk of infection than women who have a vaginal delivery.[12]

Antibiotic prophylaxis can help decrease the risk of infection from cesarean section by 60% to 70%.[12] Prophylactic antibiotics should be given preoperatively rather than after umbilical cord clamping.[13] The choice of antibiotic depends on the clinical scenario and whether the patient has any allergies. Antibiotics should cover gram-positive and gram-negative bacteria, as well as some anaerobes.[14]

A single intravenous dose of 1 g of cefazolin is routine for women weighing less than 80 kg, and the dose increases to 2 g for patients weighing 80 kg or more. For women weighing 120 kg or more, there is a consideration for increasing the dose of cefazolin to 3 g to achieve adequate tissue concentrations of the antibiotic.[15] For patients with a contraindication to cefazolin, such as a significant allergy, prophylaxis with clindamycin 900 mg and an aminoglycoside 5 mg/kg is recommended. An allergy merits significant consideration if evidenced by urticaria, respiratory distress, angioedema, or anaphylaxis. Adding a single dose of vancomycin is recommended in patients with a history of methicillin-resistant Staphylococcus aureus. 

Due to the nature of the cesarean section, infection risk is conferred by vaginal flora in addition to skin flora. Women undergoing cesarean delivery after labor or rupture of membranes have increased exposure to vaginal bacteria. More recent research has found that, for these women, the addition of 500 mg of azithromycin intravenously to traditional antibiotic prophylaxis is beneficial for reducing infectious morbidity.[16] 

Topical preparations have also been utilized to decrease infection after cesarean section. Topical povidone-iodine and chlorhexidine have both been found to be effective for abdominal skin preparation. Research is mixed and of generally low quality; however, there may be some evidence that chlorhexidine is superior to povidone-iodine in reducing infection.[17] Given the data is not clear, both options are considered acceptable.

In addition to abdominal skin preparation, vaginal preparation should also be a consideration. A Cochrane review team recently examined this topic and concluded that vaginal preparation probably does reduce the risk of endometritis after cesarean section.[18] Both povidone-iodine and chlorhexidine solutions are reasonable options.  

Technique or Treatment

Cesarean section is a complicated procedure. Appropriate tissue handling, adequate hemostasis, avoiding tissue ischemia, and preventing infection are essential for wound healing and reducing subsequent adhesion formation. Several methods are utilizable at each step or tissue layer during the surgery. Many factors contribute to a surgeon’s decisions on technique. As with any aspect of medical practice, basing those decisions on evidence is recommended. The 4 main techniques for cesarean delivery include the Pfannenstiel-Kerr method, the Joel-Cohen method, the Misgav-Ladach method, and the modified Misgav-Ladach method.

Before cesarean, the pubic hair may be removed or not. Those advocating for hair removal claim decreased surgical site contamination and infection. However, a Cochrane review did not show lower infection rates with hair removal. Therefore, hair removal should only occur if it provides improved visualization. Hair removal should be performed with clippers rather than razors. Patients should also be discouraged from shaving their pubic area as they approach their gestational due dates or scheduled cesarean section dates. Shaving with a razor may cause microscopic skin breaks that are associated with more surgical site infections compared to clipping.

The initial skin incision can be made either in a suprapubic transverse or midline vertical fashion. A vertical midline incision is considered to provide faster access to the abdominal cavity, and it disrupts fewer tissue layers and vessels, leading to many citations as the preferred method to perform an emergency cesarean.[19] A vertical incision may also allow visualization away from known severe adhesive disease. In the case of a planned cesarean hysterectomy for a morbidly adherent placenta, a vertical incision may provide more surgical exposure, as well as access to the hypogastric arteries. However, a transverse skin incision is the most commonly used and is preferable in most cases due to improved wound healing and patient tolerability. As most clinicians are more adept at low-transverse cesarean entry, this technique is often used even in emergency scenarios. Unplanned cesarean hysterectomies can take place through a low transverse incision. Patient habitus may lead some surgeons to place a transverse skin incision higher on the abdomen rather than underneath the pannus, though research is not yet definitive on this technique.[20]

A Pfannenstiel skin incision is slightly curved and is located 2 to 3 centimeters or 2 fingerbreadths above the symphysis pubis. The midportion of the incision is within the hair-bearing area of the mons. The hair should be removed in this case. A Joel-Cohen incision, in contrast, is straight rather than curved. This incision is 3 cm below the line connecting the anterior superior iliac spines, making it more cephalad than a Pfannenstiel skin incision.[19]

The subcutaneous layer is under the skin and can be dissected bluntly or sharply. Blood vessels course through this layer, so care should be taken to minimize blood loss by limiting sharp dissection to the midline until the fascia is reached, then bluntly dissecting laterally. Alternatively, judicious use of cautery can maintain hemostasis if blood vessels are transected.

The fascia is then incised in the midline with the scalpel, and this incision is extended laterally, either sharply or bluntly. The fascia may then be dissected off the underlying rectus muscles. To accomplish this dissection, the superior and inferior aspects of the fascia are sequentially grasped with a clamp (such as a Kocher), and dissection can be accomplished with a combination of blunt technique as well as sharply using scissors or cautery. Care is necessary to not damage the underlying rectus muscles. However, in some clinical scenarios, the rectus muscles may be deliberately cut to provide better surgical access.

One small randomized controlled trial investigated dissection compared to nondissection of the fascia from the rectus muscles. Nondissection was associated with a slower decline in hemoglobin levels postoperatively and less pain on a visual analog scale. However, surgical time and difficulty of delivery of the fetus were not evaluated. Therefore, results from this study may not be sufficient impetus to change surgical techniques.[19]

After separating the rectus muscles in the midline, entry into the abdominal cavity is achieved by opening the peritoneum. The surgeon can do this either sharply or bluntly. If sharp entry is used, care should be taken to avoid injury to underlying structures such as the bowel. Once the entry is achieved, the peritoneal incision is usually extended bluntly. Care is necessary to prevent injury to the bladder during the extension of the peritoneal incision.

A bladder blade is often placed at this point to provide visualization of the lower uterine segment. Alternatively, a self-retaining retractor can be used. If desired, the bladder flap can be created at this point; the peritoneum overlying the bladder and lower uterine segment is grasped and incised, and the bladder is dissected off the lower uterus sharply or bluntly. Surgeons choosing to create a bladder flap do so out of a desire to decrease surgical injury to the bladder, especially during the repair of the uterine incision.[21] However, in several trials, the omission of a bladder flap decreased operative time and did not increase complications such as hematuria, pain, or urinary tract infection. Bladder injury is rare, and study results have been underpowered to detect whether the omission of the bladder flap changes the incidence of bladder injury.[19] In clinical scenarios where the risk of an inferior hysterotomy extension is high, such as a cesarean in a patient who has been wholly dilated and pushing, a bladder flap may be indicated even if not routinely performed.

With adequate visualization, whether or not a bladder flap has been created, the uterine incision can now be made. The uterus incision can be either transverse or vertical (classical). For most cesareans, a low transverse incision is preferable. Compared to a classical incision, a low transverse incision causes less bleeding, is easier to repair, and causes less adhesion formation.[22] However, there may be some instances where a classical incision is indicated. For example, a fetus in a transverse lie with the fetal back down may require a classical incision. If the lower uterine segment is underdeveloped and, therefore, does not provide room for an adequate transverse incision, a classical hysterotomy may be necessary to provide an atraumatic delivery of the fetus.[22] This scenario may occur in early preterm gestations. In some clinical scenarios, such as in severe adhesive disease, the lower uterine segment may not be accessible, and the surgeon must adapt.

A low vertical hysterotomy may be an option if a problematic extraction of a fetus is anticipated, especially in the case of breech presentation. A low transverse incision can also be extended vertically to create a “T,” “U,” or “J” incision to provide additional room. A patient who has had a transverse or low vertical uterine incision may be a candidate for a trial of labor in subsequent pregnancies, whereas a prior classical or “T” incision is an indication for repeat cesarean delivery.[2]

Before making the hysterotomy, the uterus can be palpated to identify any lateral rotation. Making the hysterotomy in the midline rather than laterally can help the surgeon avoid damaging the uterine vessels, especially if making a transverse incision. The incision is made carefully with a scalpel in shallow strokes, sometimes in combination with blunt dissection, taking care not to injure the fetus. If the patient has been pushing, making the incision high in the surgical field creates a low transverse incision and decreases the risk of extension into lateral vessels, the lower uterus, or the cervix.

Upon achieving uterine entry, the uterine incision can be extended laterally either bluntly with fingers or sharply with bandage scissors. Blunt extension of the uterine incision is preferred if possible, as a sharp extension is associated with increased maternal morbidity and blood loss. Compared to a blunt transverse extension, a blunt cephalad-caudad extension of the hysterotomy decreases unintended extension and significant blood loss.[19] Thus, a blunt extension of the hysterotomy in a cephalad-caudad fashion is preferred.

If the uterine myometrium is thick, as in earlier gestations or a classical hysterotomy, bandage scissors may be necessary. An inadequate hysterotomy may increase the risk of difficult fetal extraction, which, in turn, may lead to an increase in neonatal morbidity or mortality. Safe delivery of the fetus is the ultimate goal of cesarean delivery, regardless of the details of the technique.

Delivery of a fetus in the vertex presentation is achieved by inserting a hand into the uterine cavity and elevating the fetal head into the hysterotomy. If the head cannot be elevated, an assistant may provide additional elevation from below via a hand in the patient’s vagina. Alternatively, a vacuum cup or a single forceps blade may elevate the fetal head. After elevating the fetal head into the incision, the bladder blade is removed, and fundal pressure is applied to expel the fetus out of the uterus. The surgeon guides the head gently during the process, and the surgical assistant may be instrumental in providing most of the fundal pressure. If fundal pressure is inadequate, or if it cannot be adequately achieved (such as significant maternal obesity), a vacuum cup can be applied to the fetal head for an assisted delivery. Forceps can also be placed at the time of cesarean delivery. The usual rules apply when using a vacuum or forceps, even in cesarean delivery.

If a fetus is in the breech presentation, the clinician identifies the fetal lie by palpation inside the uterine cavity. There are several techniques for delivering a breech fetus, either by grasping the feet or the hips to bring the fetus into the hysterotomy. The fetus can be delivered to the level of the shoulders with gentle traction, sometimes with the assistance of a surgical towel around the fetus. The bilateral arms are sequentially swept down and delivered. Fundal pressure is then used to help flex and deliver the fetal head. The Mauriceau-Smellie-Veit maneuver may also be used to flex the fetal head; this involves placing the first and third fingers of 1 hand on the fetal cheekbones, placing the second finger in the fetal mouth, and pulling the jaw down. The application of Piper forceps is rarely needed to deliver the fetal head.

After delivery of the fetus, the umbilical cord is doubly clamped and cut. Cord clamping may be delayed if the maternal and fetal statuses allow and if the surgeon desires. A systematic review of delayed umbilical cord clamping in preterm infants showed a reduction of in-hospital mortality, a reduced incidence of low Apgar scores at 1 minute but not 5 minutes, no change in other outcome measures (eg, intubation, intraventricular hemorrhage, or necrotizing enterocolitis), and a potential risk for induced polycythemia and hyperbilirubinemia.[23] One randomized controlled trial investigating delayed cord clamping in elective cesarean deliveries provided results showing increased neonatal hematocrits without an increased need for phototherapy.[24]

After cutting the umbilical cord, cord blood can be collected if necessary or desired. The placenta is then delivered, accomplished via manual removal or spontaneously via cord traction and fundal massage. Due to data showing a reduction in operative blood loss and a decrease in infections, spontaneous placental delivery is preferable if the clinical scenario allows it.[25][26] After the placenta is delivered, the uterine cavity is wiped out with moist laparotomy sponges.

For the repair of the hysterotomy, the uterus can be exteriorized or left in situ. Research results have demonstrated similar rates of febrile complications and similar surgical time with the 2 techniques, so the decision can depend on clinician preference.[19] As for the repair itself, a delayed absorbable suture is used running, taking care to incorporate the corners of the incision while avoiding the lateral vessels. A running closure decreases operating time and blood loss compared to an interrupted closure.

Closing the hysterotomy in 1 versus 2 layers has been studied. Short-term outcomes such as infectious morbidity, pain, blood transfusion, and hospital readmission were not different between the 2 techniques.[27] Data on whether a single-layer closure decreases operative time and operative blood loss is mixed.[19][21] For women desiring a future trial of labor, there is evidence showing an improved residual myometrial thickness and scar healing and decreased uterine rupture in subsequent pregnancies if utilizing a 2-layer closure.[19][28][29] An unlocked closure technique may also be preferable to a locked technique.[28][29] One recent study result suggested that endometrium-free closure of the uterus was associated with decreased placental abnormalities, such as placenta accreta, in subsequent pregnancies.[30] Research is ongoing regarding this specific aspect of uterine closure at the time of cesarean section.

Once the uterus is closed and hemostasis assured, the posterior cul-de-sac is cleared of blood and clot using laparotomy sponges or suction. This step may be omitted if the uterus has not been exteriorized. With the uterus returned to the abdomen, the abdomen again gets cleared of blood and clots. The assistance of various retractors may provide exposure to the paracolic gutters. Intrabdominal irrigation before closure has been shown to increase nausea during the surgery and did not improve the return of gastrointestinal function or incidence of infectious morbidity. With the bladder blade reinserted, the hysterotomy repair is again visualized and made hemostatic if necessary. The bladder blade is again removed.

The peritoneum can be reapproximated at this time. Closure of the peritoneum adds operative time and may increase postoperative fever and length of hospital stay. The decision to close this layer often hinges on the surgeon’s interpretation of the literature regarding whether closure decreases adhesion formation. Unfortunately, this data is mixed; therefore, it is the surgeon’s prerogative to balance the risks and benefits to the patient.[19]

Before the fascia is closed, the rectus muscles and the subfascial tissues are inspected to ensure hemostasis. The rectus muscles can be reapproximated in advance of fascial closure. Some clinicians believe that suturing the muscles reduces the risk of subsequent diastasis recti and decreases the incidence of intra-abdominal adhesion formation.[31] Conversely, reapproximating the muscles leads to increased postoperative pain.[31] Given time, the surgeon may involve the patient in shared decision-making regarding this technique.

The fascia is then closed using a delayed-absorbable suture in a running nonlocking fashion. Historically, some have closed the fascia in an interrupted fashion, but this technique is no longer widely used. Using a monofilament rather than a braided suture may decrease the risk of infection and should be considered in patients at higher risk of developing this complication.[32] Monofilament suture may also reduce the risk of subsequent hernia formation.[33] No data favors either option regarding the closure of the entire incision using a single suture versus 2 sutures that meet in the midline.[21]

The subcutaneous tissues are then irrigated, and hemostasis is assured. Interestingly, wound irrigation has not been shown to decrease infection rates. However, it may help to visualize better any areas requiring cautery. Closure of the subcutaneous space is recommended if the thickness is 2 cm or more, as this decreases the risk of hematoma, seroma, wound infection, and wound separation.[19][21] Drain placement in the subcutaneous space is not recommended.[19]

Skin closure may be accomplished using various methods, the most common being surgical staples or subcuticular sutures. Subcuticular absorbable staples and adhesive glues are also available. Research results have shown that both sutures and staples are similar regarding cosmesis. Though the data is conflicting, study results show subcuticular suture closure is superior to staples in terms of wound separation and wound infection.[19][21] Again, a monofilament suture may provide less of a nidus for infection than a braided suture.

A summary of the 4 general operative methods is as follows:

Pfannenstiel-Kerr method

• Pfannenstiel skin incision
• Sharp dissection of the subcutaneous layer
• Sharp extension of the fascial opening
• Sharp entry into the peritoneum
• Sharp superficial, then blunt entry into the uterus
• Manual removal of the placenta
• Single-layer interrupted closure of the uterus
• Closure of the peritoneum
• Interrupted closure of the fascia
• Continuous suture of the skin

Joel-Cohen method

• Joel-Cohen skin incision
• Blunt dissection of the subcutaneous layer
• Blunt extension of the fascial opening
• Blunt entry into the peritoneum
• Sharp superficial, then blunt entry into the uterus
• Spontaneous removal of the placenta
• Single-layer interrupted closure of the uterus
• Nonclosure of the peritoneum
• Interrupted closure of the fascia
• Continuous suture of the skin

Misgav-Ladach method

• Joel-Cohen skin incision
• Blunt dissection of the subcutaneous layer
• Blunt extension of the fascial opening
• Blunt entry into the peritoneum
• Sharp superficial, then blunt entry into the uterus
• Manual removal of the placenta
• Single-layer running closure of the uterus
• Nonclosure of the peritoneum
• Continuous closure of the fascia
• Mattress suture closure of the skin

Modified Misgav-Ladach method

• Pfannenstiel skin incision
• Blunt dissection of the subcutaneous layer
• Blunt extension of the fascial opening
• Blunt entry into the peritoneum
• Sharp superficial, then blunt entry into the uterus
• Spontaneous removal of the placenta
• Single-layer running closure of the uterus
• Closure of the peritoneum
• Continuous closure of the fascia
• Continuous suture of the skin [19]

Anesthesia/Pain Control

Patient comfort during cesarean section is most often the responsibility of the anesthesiology team. A regional anesthetic placed before surgery, such as a spinal or epidural block, is common. Regional anesthetics minimize fetal exposure to any agents that may suppress respiration or otherwise impact the newborn transition. Cesarean section can also be performed under general anesthesia with endotracheal intubation. When a cesarean is performed under general anesthesia, the surgery is often performed with greater speed, often utilizing more blunt dissection to minimize fetal exposure to the anesthetics. If an anesthesiology healthcare professional is not readily available in an urgent or emergent case, a cesarean section can be performed using a local anesthetic. 

Complications

The maternal mortality rate in the United States is approximately 2.2 per 100,000 cesarean deliveries. Though this rate is low overall, it is significantly greater than for vaginal delivery. The maternal mortality rate for a vaginal birth is approximately 0.2 per 100,000.[34] As with any delivery and with surgery in general, there is a risk of excessive bleeding during and after a cesarean section; hemorrhage is the leading cause of serious maternal morbidity in the United States.[35] Certain conditions preceding a cesarean, such as prolonged labor, fetal macrosomia, or polyhydramnios, may increase the risk of uterine atony and subsequent hemorrhage. Intraoperative conditions such as the need for significant adhesiolysis or extension of the hysterotomy laterally into the uterine vessels may also lead to excessive blood loss. Hemorrhage during delivery may then lead to the need for blood product transfusion, which itself carries risks of complications. Approximately 10% of maternal mortality in the United States is secondary to obstetric hemorrhage.[35] Sheehan syndrome is a known complication of hemorrhage at delivery.[35] 

Infection is a significant risk after cesarean delivery. In addition to postpartum hemorrhage, wound infection, and endometritis are the other common complications after a cesarean section. Results from a study examining the efficacy of vaginal cleansing revealed that postoperative endometritis was reduced from 8.7% to 3.8% with cleansing.[18] Further, results from a study investigating adjunctive azithromycin showed a decrease in wound infection from 6.6% to 2.4% with the additional antibiotic, and serious adverse events decreased from 2.9% to 1.5%.[16] However, given that more than a million women have cesarean sections every year, these percentages still represent a significant number of women with infectious complications.

Data reported in 2010 showed that the overall risk of infectious morbidity in elective repeat cesarean deliveries was 3.2%, compared to 4.6% in women undergoing a trial of labor. The same data reported elective repeat cesareans to have a blood transfusion rate of 0.46%, a surgical injury rate of 0.3% to 0.6%, and a hysterectomy rate of 0.16%.[2] Thromboembolism and anesthetic complications can also occur.

While cesarean section is safer for the fetus, there are risks to fetal delivery with this approach. The risk of fetal trauma during cesarean is approximately 1%, including skin laceration, fracture of the clavicle or skull, facial or brachial plexus nerve damage, and cephalohematoma.[36] Overall, these risks are lower than in vaginal deliveries. Regarding the neonate, there are risks of respiratory complications and higher rates of asthma and allergy in those born via cesarean section compared to vaginal delivery.[2][37] In 2010, transient tachypnea of the newborn was reported in 4.2% of elected repeat cesareans, and the need for bag-and-mask ventilation was 2.5%.[2]

In addition to short-term surgical risks, cesarean delivery also confers long-term risks, both to the patient and any subsequent pregnancies. A vertical uterine scar requires a patient to deliver subsequent pregnancies via cesarean section. As the number of cesarean sections increases, so too do the surgical risks. Adhesion formation can make each subsequent cesarean delivery more difficult and increase the risk of inadvertent injury. The risks of abnormal placentation also increase with each successive operation. For a woman who has had 1 cesarean section, the risk of placenta accreta is 0.3%, while the risk increases to 6.74% with 5 or more cesarean deliveries.[38] A morbidly adherent placenta carries with it a risk of significant hemorrhage and possible loss of fertility if a hysterectomy becomes necessary.

Clinical Significance

Approximately 1.3 million women in the United States undergo a cesarean section each year; the procedure is the most common operation performed in the United States. The said patient did not survive the first documented cesarean, performed in AD 1020, but medicine has advanced significantly since then. Understanding all the risks and benefits of a cesarean section allows a clinician to counsel a pregnant patient appropriately.

A clear understanding of evidence-based medicine enables clinicians to provide the best care and outcomes. Patients sometimes request a cesarean delivery without clinical indications, and healthcare professionals should be equipped to provide the significant education needed in these cases to ensure the patient is making an informed decision. There is growing pressure to decrease cesarean section rates, so a proper understanding of the appropriate indications will assist clinicians and patients in decision-making.

Enhancing Healthcare Team Outcomes

Coordination and communication between interprofessional healthcare team members are crucial to ensuring safety and optimal outcomes in cesarean delivery. Two-thirds of sentinel events are caused by failure to communicate.[39] Crew resource management, safety bundles, and checklists have all been used to improve safety and communication. At its most fundamental, the surgical “time-out” ensures everyone in the operating suite is on the same page. The Joint Commission requires that a time-out be held before all procedures.

The Patient Safety Checklist for planned cesarean delivery created by the American College of Obstetricians and Gynecologists is an example of using a checklist to improve safety. This checklist involves all team members, including the surgeon, nurses, anesthesia team, and patient, working together in an interprofessional approach. The checklist asks questions that include the following:

• Does the patient have a complete medical history and physical examination?

  • Have known allergies been identified?
  • Does the patient have medical factors affecting anesthetic choices?
• Has the patient been counseled about risks, benefits, indications, and alternatives?

  • Is the consent form signed?
• Are appropriate laboratory results available?
• Has appropriate antibiotic prophylaxis been given?
• Is appropriate deep vein thrombosis prophylaxis being utilized?
• Have the fetal heart tones been confirmed?
• Are there any additional risk factors identified?

  • Bleeding risk
  • Airway
  • Allergies
  • Need for neonatal or pediatric departments
• Has a time-out been conducted, including identification of the patient, allergies, consent, and surgical procedure, and confirmation of all the team roles?
• Have surgical counts been performed before the first incision?[40] 

TeamSTEPPS, “Team Strategies & Tools to Enhance Performance & Patient Safety,” is a nationally recognized crew resource management curriculum utilized by multiple health systems.[41][42] The curriculum is an evidence-based system for teamwork designed to improve the quality, safety, and efficiency of health care. One of the goals of TeamSTEPPS is to empower each healthcare team member, no matter their role, to speak up when there is a safety concern.

Feeling intimidated in the workplace is common, and medicine is no exception. Intimidation may discourage members of the healthcare team from speaking up. Individuals should, therefore, possess the tools that empower them to be a part of a culture of safety. TeamSTEPPS encourages using the “CUS” framework: I am Concerned, I am Uncomfortable; this is a Safety issue. Another tool utilized is a “hard stop,” a safety phrase that, when invoked, leads to a cessation of activity and allows for communication of a safety concern.

Simulation training is often utilized to practice team dynamics and identify areas for improvement. Two scenarios targeted by simulation are an emergency cesarean section and a postpartum hemorrhage. Roles can be clarified, and communication streamlined via simulation.

Debriefing among the healthcare team is yet another tool to ensure adequate communication regarding the procedure that just occurred.[43] A debrief assists with consistent documentation of the procedure and its details, and also allows feedback regarding what went well and what might be improved. A debrief can be standard after every cesarean, but it should be a strong consideration after urgent or emergent cases or after instances in which there were complications.

Using the above framework for teamwork and communication requires an interprofessional team approach, including physicians, specialty-trained nurses, pharmacists, and other healthcare professionals collaborating across disciplines to achieve optimal patient results. Physicians hold the primary responsibility for the surgical procedure, while advanced clinicians and nurses ensure patient readiness, monitor intraoperative status, and manage postoperative care. Pharmacists are responsible for proper medication management, and all team members contribute to assessing risks and anticipating complications. Through collaboration, shared responsibility, and a commitment to patient-centered care, healthcare teams can significantly enhance outcomes, improve safety, and boost overall team performance in managing cesarean sections.

Nursing, Allied Health, and Interprofessional Team Interventions

The nurse’s role is vital before, during, and after a cesarean section. Much like a primary care clinician is the coordinator for a patient’s health across multiple locations and specialties, the nurse is a patient’s touchstone during the process of cesarean delivery. Both having a baby and having surgery are 2 subjects that can cause a patient significant anxiety, and a nurse’s ability to reassure and communicate with the patient has been shown to improve patient satisfaction and reduce stress.[44] During regional anesthesia placement, the nurse holding that patient’s hand and talking her through the process can make all the difference.

The nurse meets the patient preoperatively, thus beginning her relationship with that patient. If the patient has an unscheduled cesarean, the nurse may have been helping to manage the patient during that prior time. Often, the nurse obtains the patient’s medical history and enters it into the electronic health record. The nurse ensures that the appropriate labs are obtained and verifies the results. The nurse places the indwelling Foley catheter, and the nurse performs the surgical skin preparation. When the fetus is delivered, the nurse usually assumes care of the infant and performs the resuscitation. The nurse is also the primary source of communication between the operating room and those outside. This activity may include updating others on the status of the surgery, or it could be returning a page and informing the inquiring person that the surgeon is busy.

Many nursing details and actions combine to make a cesarean section successful. Nurses play a critical role in cesarean deliveries by providing essential preoperative, intraoperative, and postoperative care. They ensure patient safety, monitor vital signs, manage pain, and offer emotional support while coordinating with the surgical team to ensure smooth and efficient procedures. Their involvement directly impacts both maternal and neonatal outcomes.

Nursing, Allied Health, and Interprofessional Team Monitoring

The nurse has a crucial safety role during a cesarean section. During the time-out, the nurse must speak up and alert the team if an essential part of the safety checklist is absent. If a surgeon breaks sterility during the surgery, the nurse may notice. The nurse calls for additional assistance if the newborn is not doing well. The nurse also monitors the patient's status postoperatively and reports on the following:

• Vital signs of the mother
• Vital signs of the newborn
• Symptoms and/or signs of infection
• Symptoms and/or signs of breast engorgement
• Maternal urine output
• Uterine involution
• Ambulatory level of the mother
• Wound dressing
• Amount of blood loss
• Amount of blood and/or serous discharge from the drain, if any

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Disclosure: Sharon Sung declares no relevant financial relationships with ineligible companies.

Disclosure: Beverly Mikes declares no relevant financial relationships with ineligible companies.

Disclosure: Heba Mahdy declares no relevant financial relationships with ineligible companies.