Cesarean delivery is the most common surgical procedure performed in the United States, with nearly 1.3 million cases performed each year.¹ The rate of cesarean sections (C-sections) has steadily increased over the past several decades, reaching a peak of 32.9% in 2009. The incidence has since slightly declined, with 32.0% of all deliveries performed via C-section in 2015.¹ Trends in the rate of cesarean delivery are affected by both the primary cesarean delivery rate as well as the rate of vaginal birth after cesarean (VBAC). This chapter will review the common indications for cesarean delivery, the risks and benefits pertinent to informed consent for cesarean delivery, and the key steps involved in the procedure as well as evidence-based steps for preventing postcesarean complications.

Appropriate knowledge of the anterior abdominal wall is necessary to perform cesarean delivery. The layers encountered when making a low-transverse abdominal wall incision include the following:

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  Skin

  
  
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  Subcutaneous tissue, including the superficial fatty layer of Camper’s fascia and the deeper, membranous Scarpa’s fascia

  
  
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  The thicker rectus fascia created by the aponeurosis of the external and internal obliques and the transversus abdominis muscles

  
  
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  The midline muscles of the anterior abdominal wall: the rectus abdominis and the pyramidalis

The dermal fibers of the skin are arranged transversely, creating Langer’s lines. Transverse incisions, such as the Pfannenstiel incision, are parallel to these lines and result in less tension and better cosmetic results than vertical midline incisions.

At the level of a low-transverse incision, the fascia entirely overlies the rectus muscles. Above the arcuate line, which is located halfway between the umbilicus and the pubic crest, this fascia splits and envelops the rectus abdominis muscles.

The blood supply to the anterior abdominal wall includes the superficial epigastric vessels. These vessels may be encountered surgically in the subcutaneous tissue as they course diagonally from the femoral artery toward the umbilicus. Also of surgical relevance are the inferior epigastric vessels, which arise from the external iliac arteries and course lateral to and then posterior to the rectus abdominis muscles. These vessels may be encountered lateral to the rectus muscle belly during transection of the rectus muscles in a Maylard incision.

The T10 dermatome is at the level of the umbilicus, so regional anesthesia for cesarean delivery ideally blocks T10–L1 levels. In addition, two superficial nerves are anatomically relevant. The iliohypogastric nerve perforates the external oblique and runs lateral to the rectus muscle, providing sensation to the suprapubic area. The ilioinguinal nerve exits the inguinal ring, courses on the far lateral abdominal wall, and supplies the skin of the mons pubis, labia majora, and upper thigh. Both nerves can be injured or entrapped with transverse incisions that extend lateral to the rectus muscles, which can result in pain or loss of sensation (Fig. 60-1).

Cesarean delivery, is performed when vaginal delivery is either impossible or presents significant risks to the mother or baby. Although some indications are straightforward, the decision for cesarean delivery often involves careful decision-making, balancing the maternal risk of the procedure against the maternal and fetal risks of vaginal delivery. Box 60-1 shows the most common indications. The most common indication for cesarean delivery in women over age 25 is a previous cesarean.²

Most women with one previous cesarean and a low-transverse uterine incision are candidates for VBAC in future pregnancies. However, any trial of labor after a cesarean delivery must be performed after appropriate patient counseling and in a facility with staff available to provide immediate delivery.³ There are few relative and no absolute contraindications to cesarean delivery. According to the American College of Obstetricians and Gynecologists (ACOG), in the absence of maternal or fetal indications for cesarean delivery, a vaginal delivery is the safest option and should be recommended.⁴

As with all procedures, the provider must obtain informed consent prior to performing cesarean delivery. This consent involves reviewing the indication for the cesarean delivery and discussing any alternatives as well as potential risks and complications of the procedure and those of each alternative. In most cases, safe alternatives are limited but may include operative vaginal delivery. Risks of the procedure include the risk of blood loss, with the possible need for transfusion. In addition, compared to vaginal delivery, cesarean deliveries carry higher risks of infectious complications, including endometritis, superficial and deep surgical site infections, wound hematomas or seromas, and wound breakdown. There is also a risk of inadvertent damage to surrounding organs during the surgery, including bowel, bladder, or ureteral injury. There is an increased rate of thromboembolic disease associated with cesarean delivery, and mortality and hysterectomy rates, while low, are higher than with vaginal delivery. Finally, long-term risks of having a C-section must be considered. Cesarean delivery is associated with increased risk of future miscarriage, abnormal placentation requiring hysterectomy, and uterine rupture in subsequent pregnancies.⁵

Despite these risks, cesarean delivery also has some benefits. When done for appropriate reasons, C-sections carry a lower risk to both mother and baby than vaginal delivery. Cesarean delivery allows expedient delivery of a potentially compromised fetus. In addition, cesarean delivery is associated with lower rates of stress incontinence and pelvic organ prolapse than vaginal delivery.⁶

PREOPERATIVE INFECTION PREVENTION

Preoperative antibiotic administration prior to surgical incision has been shown to decrease postoperative infectious morbidity significantly.^7,8 ACOG recommends a single dose of a first-generation cephalosporin such as cefazolin, generally with an intravenous (IV) dosage of 2 g, with consideration of a higher dosage such as 3 g for obese patients with a body mass index (BMI) ≥ 30 kg/m².⁹ For penicillin-allergic patients, ACOG recommends a single dose of clindamycin with an aminoglycoside such as gentamicin.⁹ A well-designed randomized control trial (RCT) suggested a reduction in postcesarean infectious morbidity with the addition of 500 mg of azithromycin IV as broader coverage when C-section is performed on women in labor, or after the rupture of membranes.¹⁰

In addition to antibiotic administration, preoperative skin preparation helps reduce infection. Data from the general surgery literature as well as a high-quality RCT in obstetrics illustrate the benefit of chlorhexidine-alcohol solution over iodine-alcohol solutions.^11,12 We recommend chlorhexidine-alcohol as the skin antisepsis of choice. In emergency situations, chlorhexidine-alcohol provides superior antisepsis to iodine even without drying, but electrocautery cannot be used for the first 3 minutes of the procedure until the solution has dried. Also, several studies have evaluated preoperative vaginal cleansing with povidone-iodine solution, with varying results; some illustrate benefits, particularly among patients in labor and those with ruptured membranes. However, the largest US-based study found no benefit.^13,14 There is currently inadequate evidence to recommend for or against routine vaginal cleansing prior to C-section. A checklist of procedures to perform prior to a C-section is given in Box 60-2.