Key Abbreviations
American College of Obstetricians and Gynecologists ACOG
Cephalopelvic disproportion CPD
Cesarean delivery CD
Computed tomography CT
Delayed cord clamping DCC
Deep venous thrombosis DVT
Fetal heart rate FHR
Hypoxic-ischemic encephalopathy HIE
National Institutes of Health NIH
Pulmonary embolism PE
Randomized controlled trial RCT
Relative risk RR
Trial of labor after cesarean TOLAC
Vaginal birth after cesarean VBAC
Venous thromboembolism VTE
Definitions
Cesarean delivery (CD) is defined as birth of a fetus from the uterus through an abdominal incision. The terms cesarean delivery or cesarean birth are preferred as opposed to cesarean section . Primary cesarean refers to a CD done in a woman without a prior cesarean birth, whereas repeat cesarean refers to a CD done in a woman who had a cesarean birth in a previous pregnancy. This chapter reviews the history, incidence, indications, techniques, and complications of CD as well as tubal sterilization.
History of Cesarean Delivery
CD has been described since ancient times, and evidence exists from both early Western and non-Western societies of this surgical procedure being performed. The evolution of the term cesarean has been debated over time. Although originally believed to have been derived from the birth of Julius Caesar, it is unlikely that his mother, Aurelia, would have survived the operation; her knowledge of her son’s invasion of Europe many years later indicates that she survived childbirth. In Caesar’s time, surgical delivery was reserved for when the mother was dead or dying. Roman law under Numa Pompilius the first (“Lex Regia”), then renamed after Caesar (“Lex Cesarea”), specified surgical removal of the fetus before burial of the deceased pregnant woman; religious edicts required separate burial for the infant and mother. The term cesarean may also refer to patients being cut open, because the Latin verb caedare means to cut. Cesarean operation was the preferred term before the 1598 publication of Guillimeau, who introduced the term section .
Although sporadic reports of heroic life-saving efforts through cesarean childbirth existed for hundreds of years, it was not until the latter part of the nineteenth century that the operation became established as part of obstetric practice. This coincided with the gradual transition of childbirth as primarily a midwife-attended event, often in rural settings, to an urban hospital experience. The wide emergence of hospitals laid the foundation for establishing obstetrics as a hospital-based specialty. As new methods for anesthesia emerged, CD for obstructed labor gained popularity over destructive procedures, such as craniotomy, that accompanied difficult vaginal births. Despite the dangers that still existed with CD, the operation was viewed as preferable to a difficult high forceps delivery, which was associated with fetal injury and deep pelvic lacerations. Although refinements in anesthesia techniques allowed the operation to be performed, mortality rates remained very high, with sepsis and peritonitis as leading causes of postoperative deaths. Primitive surgical techniques and lack of antisepsis clearly contributed to morbidity. Surgeons attempted to complete the operation without closing the uterus, fearing that the suture material itself would promote infection and that the uterus would best heal by secondary intention. As a result, women were placed at risk for both hemorrhage and infection.
Lebas first advocated suturing the uterus after CD in 1769. Traditionally, sutures were not used inside the abdomen or pelvis because they were considered impossible to remove once the cavity was closed. In 1876, Eduardo Porro advocated for supracervical hysterectomy and bilateral salpingo-oopherectomy during CD to control bleeding and to prevent postoperative infection. Shortly thereafter, surgeons gained experience with internal suturing because silver-wire stitches were developed by the gynecologist J. Marion Sims, who had perfected the use of these sutures in the treatment of vesicovaginal fistulae resulting from obstructed labors. In the early 1880s, two German obstetricians, Ferdinand Adolf Kehrer (1837-1914) and Max Sänger (1853-1903), both independently proposed a transverse incision of the lower segment of the uterus, at the level of the internal cervical os, and developed two-layer uterine closure methods with the sutures used by J. Marion Sims. Another pivotal contribution was made in 1900 by Hermann Johannes Pfannenstiel (1862-1909), a German gynecologist who described a transverse suprapubic incision, or pelvic skin incision.
As gynecologic surgeons performed more CDs and the outcomes improved, greater attention was placed on technique, including the site of the uterine incision. Between 1890 and 1925, more and more surgeons began using transverse incisions of the uterus. John Martin Munro Kerr (1868-1960), a professor of Obstetrics Midwifery at the University of Glasgow, popularized the Pfannenstiel skin incision and lower segment uterine incision and is considered the “father” of the modern CD. It was noted that such incisions reduced the rate of infection and the risks of incisional hernia and rupture with subsequent pregnancies compared with the vertical incisions. However, before the advent of antibiotics, owing to the risk for peritonitis, extraperitoneal cesarean was advocated by Frank (1907), Veit and Fromme (1907), and Latzko (1909) and was popularized by Beck (1919) in the United States. Interestingly, the vertical opening of the abdomen was still the main technique used in the 1970s, although it was known from the beginning of the twentieth century to be associated with higher rates of long-term postoperative complications, such as wound dehiscence and abdominal incision hernia, and it is also cosmetically less pleasing.
The introduction of penicillin in 1940 dramatically reduced the risk for peripartum infections. As antibiotic therapy emerged, the need for extraperitoneal dissection diminished. As technology developed, including improved anesthesia, and the medical management of pregnancy and childbirth accelerated, CD became more commonplace in obstetrics. Given its current safety and effectiveness, a liberalized approach to using cesarean childbirth has emerged in developed countries over the past 40 years.
Incidence
The CD rate describes the proportion of women undergoing CD of all women giving birth during a specific time period. The CD rate may be further subdivided into primary and repeat CD rates, both as a proportion of the entire obstetric population. CD rates have risen in the United States in a dramatic fashion from less than 5% in the 1960s to 32.7% by 2013, with stable rates around 32% to 33% in the last 5 years or so. CD accounts for more than 1 million major operations performed annually in the United States. It is the most common major surgical procedure undertaken today in the United States and around the world. Among the reasons for this increase are (1) a continued increase in primary CDs for dystocia, failed induction, and malpresentation; (2) an increase in the proportion of women with obesity, diabetes mellitus, and multiple gestation, which predispose to CD; (3) increased practice of CD on maternal request; and (4) limited use of a trial of labor after cesarean (TOLAC) delivery due to both safety and medicolegal concerns. Factors responsible for increased cesarean rates are shown in Box 19-1 .
Obstetric Factors
Increased primary CD rate
Failed induction, increased use of induction
Decreased use of operative vaginal delivery
Increased macrosomia, CD for macrosomia
Decline in vaginal breech delivery
Increased repeat CD rate
Decreased use of vaginal birth after CD
Maternal Factors
Increased proportion of women >35 yr
Increased proportion of NP women
Increased primary CDs on maternal request
Physician Factors
Malpractice litigation concerns
CD, cesarean delivery; NP, nulliparous.
A recent increase in international CD rates has also been documented. Rates of about 25% to 30% are reported in some European countries, such as the United Kingdom; they are over 40% in Italy, over 50% in China, and even higher in places like Brazil and Egypt. The rise in CD rates has prompted increased interest in the indications, complications, and techniques involved with this procedure.
The World Health Organization (WHO) has proposed an incidence of CD between 10% and 15% as a target to optimize maternal and perinatal health. However, it is not possible to determine an optimal CD rate because any ideal rate must be a function of multiple clinical factors that vary in each population and are influenced by the level of obstetric care provided. Further complicating this issue is the absence of complete and accurate data that focus on both maternal and infant outcomes. Hence, although CD rates can be considered a measure of a specific health care process (mode of delivery), these rates are not appropriate outcome measures because they do not indicate whether cesarean or vaginal birth results in optimal perinatal outcomes. Maternal and perinatal morbidity and mortality should be the outcomes monitored to ensure best quality of care. Higher CD rates (e.g., 15% to 20% compared with <5% to 10%) have been associated with better perinatal outcomes in several studies. So instead of setting goals or limits for overall CD rates, it is most important to monitor maternal and perinatal health outcomes. We would all agree with a 0% or 100% CD rate if either of these were associated with the lowest incidences of complications for mother or baby. The optimal CD rate in the early twenty-first century is in between these extremes and depends on the population. For example, Robson has suggested a helpful classification of different populations to compare cesarean rates. Class I is the most common class in most centers and includes singleton term vertex gestations admitted in spontaneous labor. Only by comparing data for similar Robson classes, or at least a similar case mix, can data regarding CD rates really be objectively evaluated. Moreover, institutions involved in tertiary obstetric care that manage a large number of preterm deliveries and maternal complications of pregnancy should have higher cesarean rates than primary care facilities. Two populations often targeted for comparison include nulliparous women with a singleton vertex gestation at 37 weeks or greater without other complications and women with one prior low transverse CD delivering a single vertex fetus at 37 weeks or greater without other complications. The use of these simple case-mix adjusted rates should make comparative evaluation of CD rates and their comparison to maternal and perinatal outcomes more meaningful. As data become more unified and methodologically sound, the quality of obstetric care can be better assessed.
In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) published an obstetric care consensus document on the safe prevention of primary CD in which several interventions were suggested to prevent unnecessary CDs ( Box 19-2 ). Institutions can indeed safely reduce cesarean birth rates through quality-improvement initiatives.
First Stage of Labor
- •
A prolonged latent phase (>20 hr in NP women and >14 hr in MP women) should not be an indication for CD. (Grade 1B)
- •
Slow but progressive labor in the first stage rarely should be an indication for CD. (Grade 1B)
- •
As long as fetal and maternal status are reassuring, cervical dilation of 6 cm should be considered the threshold for the active phase in most laboring women. Thus before 6 cm of dilation is achieved, standards of active-phase progress should not be applied. (Grade 1B)
- •
CD for active-phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hr of adequate uterine activity or at least 6 hr of oxytocin administration with inadequate uterine activity and no cervical change. (Grade 1B)
Second Stage of Labor
- •
A specific absolute maximum length of the second stage of labor above which all women should be delivered operatively has not been identified. (Grade 1C)
- •
Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following:
- •
At least 2 hr of pushing in MP women (Grade 1B)
- •
At least 3 hr of pushing in NP women (Grade 1B)
Longer durations may be appropriate on an individualized basis (e.g., with the use of epidural analgesia or with fetal malposition) as long as progress is being documented. (Grade 1B)
- •
- •
Operative vaginal delivery in the second stage of labor should be considered an acceptable alternative to CD. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged. (Grade 1B)
- •
Manual rotation of the fetal occiput in the setting of fetal malposition in the second stage of labor is a reasonable alternative to operative vaginal delivery or CD. To safely prevent CD in the setting of malposition, it is important to assess fetal position throughout the second stage of labor. (Grade 1B)
Fetal Heart Rate Monitoring
- •
Amnioinfusion for repetitive variable fetal heart rate decelerations may safely reduce the CD rate. (Grade 1A)
- •
Scalp stimulation can be used as a means of assessing fetal acid-base status when abnormal or indeterminate ( nonreassuring ) fetal heart patterns (e.g., minimal variability) are present, and it is a safe alternative to CD in this setting. (Grade 1C)
Induction of Labor
- •
Induction of labor generally should be performed based on maternal and fetal medical indications and after informed consent is obtained and documented. Inductions at 41 0/7 weeks of gestation and beyond should be performed to reduce the risk of CD and the risk of perinatal morbidity and mortality. (Grade 1A)
- •
Cervical ripening methods should be used when labor is induced in women with an unfavorable cervix. (Grade 1B)
- •
If the maternal and fetal status allow, CDs for failed induction of labor in the latent phase can be avoided by allowing longer durations of the latent phase (up to 24 hr or longer) and requiring that oxytocin be administered for at least 18 hr after membrane rupture before deeming the induction a failure. (Grade 1B)
Fetal Malpresentation
- •
Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered. (Grade 1C)
Suspected Fetal Macrosomia
- •
CD to avoid potential birth trauma should be limited to estimated fetal weights of at least 5000 g in women without diabetes and at least 4500 g in women with diabetes. The prevalence of birthweight of 5000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise. (Grade 2C)
- •
Women should be counseled about the IOM maternal weight guidelines in an attempt to avoid excessive weight gain. (Grade 1B)
Twin Gestations
- •
Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by CD. Thus women with either cephalic/cephalic–presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery. (Grade 1B)
Other
- •
Individuals, organizations, and governing bodies should work to ensure that research is conducted to provide a better knowledge base to guide decisions regarding CD and to encourage policy changes that safely lower the rate of primary CD. (Grade 1C)
CD, cesarean delivery; IOM, Institute of Medicine; MP, multiparous; NP, nulliparous.
Indications for Cesarean Delivery
CD can be performed for maternal-fetal, fetal, and maternal indications. The most common current indications are, in order of frequency, (1) failure to progress, also called cephalopelvic disproportion (CPD) or dystocia (about 30%); (2) prior cesarean (30%); (3) nonreassuring fetal heart rate (FHR) patterns (10%); and (4) fetal malpresentation (10%). Indications are listed by category in Box 19-3 . Looking at just the first CD, the common indications are shown in percentages in Figure 19-1 .
Maternal-Fetal Indications
Most CDs are performed for conditions that might pose a threat to both mother and fetus if vaginal delivery occurred. Complete placenta previa and placental abruption with the potential for hemorrhage are clear examples. Dystocia presents a risk for both direct fetal and maternal trauma, and it may also compromise fetal oxygenation and metabolic status. The suggestions for definitions of arrest of labor in the first and second stage and failed induction, shown in Box 19-2 , should be followed for management as long as maternal and fetal conditions are reassuring.
Fetal Indications
Fetal indications are primarily recognized by nonreassuring FHR testing with the potential for long-term consequences of metabolic acidosis. Continuous FHR monitoring is associated with a significant reduction in neonatal seizures and remains the most commonly used modality for fetal monitoring in labor. Scalp stimulation can be used to ameliorate the high false-positive rate of continuous FHR monitoring (see Box 19-2 ). Unfortunately, pulse oximetry, ST-segment monitoring, and other modalities have not been shown to affect neonatal outcomes or CD rates (see Chapter 15 ).
Other fetal indications for CD include malpresentation, such as a breech orientation, and more than 90% of these babies in singleton gestations are delivered by cesarean. Active maternal herpes infection would be an indication for CD to reduce the risk for transmission of infection. Suspected macrosomia or the potential for fetal trauma are indications for CD only in rare circumstances (see Box 19-2 ). Fetuses with certain birth defects, such as hydrocephalus with macrocephaly and neural tube defects, have traditionally undergone CD; however, insufficient data exist to make this an absolute indication. Babies with fetal abdominal wall defects, such as omphalocele and gastroschisis, can be delivered safely vaginally, if there are no obstetric indications for cesarean.
Maternal Indications
Maternal indications for CD are relatively few and can be considered as medical or mechanical in nature (see Box 19-3 ). Most of these indications are not based on evidence from randomized controlled trials (RCTs). Certain maternal cardiac conditions, such as a dilated aortic root with Marfan syndrome, are indications for CD. Central nervous system abnormalities in which increased intracranial pressure would be undesirable, such as accompanies the second stage of labor, have also led to recommendations for CD.
Alterations in the capacity of the maternal pelvis can be indications for CD. Mechanical vaginal obstruction as a result of pelvic masses such as lower segment myomata are examples. Finally, women with massive condylomata may also require CD, but this is rare.
Cesarean Delivery on Maternal Request
As CD has become safer, women have occasionally voiced their wish for a cesarean without a medical indication. This clinical scenario has been recently called “cesarean delivery on maternal request.” The lack of specificity of the term “elective” suggests the most reasonable and prudent course of action is to not use it, but rather to document the specific indication—whether medical or nonmedical—for the intervention or procedure (i.e., CD on maternal request). At times, physicians have also advocated cesarean as the preferred mode of delivery, even in the absence of accepted indications as described previously. We would term this scenario “cesarean delivery on physician request.”
The decision to plan a cesarean or a vaginal birth should be based on the best literature available with which to compare these choices. Cases in which cesarean (or vaginal) delivery is for accepted indications as described previously should be excluded from this comparison. The National Institutes of Health (NIH) and ACOG have carefully reviewed the literature on this topic. Both have reported that no quality evidence has compared planned cesarean to planned vaginal delivery because no randomized studies exist for the majority of women—those with a singleton gestation in vertex presentation at term. Moderate-quality evidence shows that planned cesarean is associated with less postpartum hemorrhage, more mild neonatal respiratory morbidity, longer maternal hospital stay, and possibly greater complications in subsequent pregnancies ( Box 19-4 ). Women who desire several children should be advised against non–medically indicated CD because of the direct association with an increasing number of CDs and increasing life-threatening complications such as placenta previa, placenta accreta, and the need for cesarean hysterectomy. Unfortunately, at times CD is performed on maternal request because of a fear of excessive pain and fear of damage to the vagina and perineum. Fear of childbirth is present in about 3% to 8% of women, who should be reassured of adequate maternal pain relief in labor and counseled regarding TOLAC. Increased maternal risks attributed to vaginal delivery also include urinary and fecal incontinence, pelvic prolapse, and sexual dysfunction. The precise contribution of vaginal delivery versus pregnancy and labor to these complications remains difficult to ascertain, and many epidemiologic studies do stratify data according to variables such as gestational age, maternal age, parity, and fetal weight.
Potential Benefits
Reduction in perinatal morbidity and mortality:
Elimination of intrapartum events associated with perinatal asphyxia
Reduction in traumatic birth injuries
Reduction in stillbirth beyond 39 weeks’ gestation
Possible protective effect against pelvic floor dysfunction
Less postpartum hemorrhage
Potential Risks
Increased short-term maternal morbidity
Increased endometritis, transfusion, and venous thrombosis rates
Increased length of stay and longer recovery time
Increased short-term neonatal morbidity
Increased mild neonatal respiratory morbidity
Increased long-term maternal and neonatal morbidity
Increased risk for placenta accreta and hysterectomy with subsequent cesarean deliveries
All remaining comparisons, which will be discussed later, are based on weak evidence and should not decisively sway clinical decisions. Perinatal mortality has been reported to be several times lower with a planned CD compared with labor and vaginal birth. Additionally, hypoxic-ischemic encephalopathy (HIE) of the newborn related to intrapartum events—including abruption, cord prolapse, and progressive asphyxia—occurs in approximately 1 in 3000 to 5000 births. Many of these cases presumably would be prevented by planned CD, as would unexplained stillbirths that occur beyond 39 weeks’ gestation. Traumatic birth injuries such as intracranial hemorrhage, fractures, and brachial plexus injury are also reduced with CD.
Overall, the maternal risks of CD have been considered marginal compared with those of vaginal delivery. Excluding indicated cesarean deliveries, rates of maternal mortality are comparable with those of vaginal delivery. Sachs and colleagues reported a CD-associated mortality rate of 22.3 per 100,000 compared with 10.9 per 100,000 for vaginal delivery; however, the rates were comparable excluding medical complications.
CD does increase maternal morbidity. Compared with vaginal birth, the rate of endometritis is increased (3.0% vs. 0.4%), yet rates of postpartum hemorrhage, transfusion, and deep venous thrombosis (DVT) are comparable. Other reports confirm increased risks for these morbidities with CD, including major complication rates as high as 4.5%. CD also presents a risk for future placental abnormalities, including placenta previa and placenta accreta. These risks increase with the increasing number of CDs performed for each woman and are substantial with more than three operations. Thus the decision to undergo CD on request must include thoughtful consideration of future childbearing plans.
When a planned CD is performed without accepted indications, at the request of either the patient or the physician, it should be performed at 39 weeks. After appropriate counseling, if the woman still insists on a CD, implementing her request is ethically permissible. Less than 10% of women prefer a CD based solely on their own desires.
Technique of Cesarean Delivery
Because more than 1.3 million CDs are performed in the United States every year, and about 20 million are done worldwide, it is extremely important to adhere to the safest, most effective technique associated with the lowest perinatal and maternal complications. Each aspect of CD should be evaluated individually, optimally by RCT, because it is impossible to evaluate the benefit of a specific technical aspect if multiple aspects are studied together. Proper universal surgical precautions aimed at preventing blood loss and infection should be used. Preferred technical aspects of CD are shown in Table 19-1 .
| STEP | EVIDENCE SUPPORTS IT: DO THIS | EVIDENCE REFUTES IT: DO NOT DO THIS | CAN BE CONSIDERED |
|---|---|---|---|
| Antibiotic prophylaxis with IV first-generation cephalosporin or ampicillin | Administer 30 to 60 min before cesarean incision. | Administer at neonatal cord clamp. | |
| Thromboprophylaxis | Use mechanical prophylaxis with graduated compression stockings or a pneumatic compression device during and after CD. | ||
| Lateral tilt | Consider a lateral tilt. | ||
| Bladder catheterization | Intraoperative catheterization is not mandatory; consider removal immediately after operation. | ||
| Vaginal povidone-iodine preparation | This can be considered. | ||
| Hair removal | Hair does not need to be removed, but if it is, use hair clippers the morning of the surgery. | Shave preoperatively. | |
| Site preparation | Use chlorhexidine-alcohol. | ||
| Drapes | Use nonadhesive drapes. | Use adhesive drapes. | |
| Prevent needle sticks | Consider blunt needles. | Consider not using sharp needles. | |
| Skin incision | Use a transverse skin incision. | ||
| Bladder flap | Do not develop a bladder flap. | ||
| Uterine incision | Make a low transverse uterine incision unless a vertical incision is indicated (see Box 19-5 ). | Make a vertical uterine incision. | |
| Uterine expansion | Use blunt uterine incision expansion with cephalad-caudad traction. | Use sharp uterine extension; use transverse traction. | |
| Cord clamping | Delay cord clamping for 30 to 120 sec for infants younger than 37 wk. | ||
| Prevention of postpartum hemorrhage | Use oxytocin 10 to 80 IU in 1 L crystalloid. | Use misoprostol in lieu of oxytocin. | Tranexamic acid and carbetocin may be considered. |
| Placental delivery | Deliver the placenta spontaneously with gentle cord traction. | Deliver the placenta manually. | |
| Abdominal irrigation | Use intraabdominal irrigation with NS to decrease maternal morbidity. | ||
| Uterine exteriorization | This is suggested to facilitate better visualization. | ||
| Cervical dilation | Do not manually or surgically dilate the cervix. | Manually or surgically dilate the cervix. | |
| Uterine repair | Use a single layer if the patient has completed childbearing (e.g., bilateral tubal ligation performed concurrently with CD). Consider a double layer otherwise. | ||
| Subcutaneous space closure | Close subcutaneous space if 2 cm or larger. | Routinely use subcutaneous drains. | |
| Skin closure | Close the transverse skin incision with suture. | Close the transverse skin incision with staples. |
Precesarean Antibiotics
Prophylactic preoperative antibiotics are of clear benefit in reducing the frequency of postcesarean endomyometritis and wound infection in both laboring and nonlaboring CDs. The timing, agents, and dosages of prophylactic antibiotics have been extensively studied. Prophylactic antibiotics should be given approximately 30 to 60 minutes before the skin incision to allow for adequate tissue concentrations; pharmacokinetic studies of cefazolin demonstrate that adequate concentration in maternal and amniotic fluid samples are attained 30 minutes after administration. The preferred agent for prophylaxis is either a first-generation cephalosporin (e.g., cefazolin) or ampicillin. For women who have an anaphylactic allergic reaction to penicillin, either metronidazole or clindamycin and gentamicin can be used. No apparent advantage has been shown with more broad-spectrum antibiotic prophylaxis (e.g., azithromycin or metronidazole), except perhaps for women who do not get antibiotic prophylaxis for CD. Single-dose therapy is as effective as multidose therapy and is therefore preferred.
For women with clinical chorioamnionitis, treatment with combination antibiotic therapy (e.g., ampicillin sodium/sulbactam sodium) supplants the need for prophylaxis if given within the appropriate time frame of cesarean skin incision. This therapy should be instituted promptly upon diagnosis of chorioamnionitis, and it should be continued until the patient exhibits a clinical response.
Precesarean Thromboprophylaxis
Because venous thromboembolism (VTE) is the leading cause of maternal mortality in developed countries, and CD increases this risk, thromboprophylaxis should be considered in all CDs. Because the incidence of clinically significant thrombosis is 0.9%, an insufficient number of women have been randomized to mechanical prophylaxis, heparin, low-molecular-weight heparin, or no anticoagulation to assess safety and efficacy of these treatment regimens in comparison to one another. We recommend mechanical prophylaxis with graduated compression stockings or a pneumatic compression device during and after every CD until ambulation resumes. Women with additional risk factors such as morbid obesity, prior VTE, or immobility may benefit from medical thromboprophylaxis after cesarean (e.g., with prophylactic heparin).
Other Prophylactic Precesarean Interventions
A lateral tilt of about 15 degrees is suggested to elevate the mother’s right side to avoid vena caval compression and supine hypotension syndrome. However, left lateral tilt, head-up or head-down position, the use of wedges and cushions, flexion of the table, and use of a mechanical displacer have been insufficiently studied to provide any strong recommendation for routine clinical use.
Vaginal preparation immediately before CD with povidone-iodine solution significantly reduces the incidence of postcesarean endometritis (from 8.3% in those who received placebo preparations to 4.3%), especially in women with ruptured membranes (17.9% reduced to 4.3%) and those in labor (13.0% reduced to 7.4%). Although antibiotics were administered prophylactically for CD in these trials, at least one trial administered antibiotics at cord clamping, and two trials did not specify the timing of antibiotic administration. Therefore it is unclear whether vaginal preparation reduces morbidity in women who receive antibiotic prophylaxis for CD preoperatively as is currently recommended.
Fixing an indwelling urethral catheter (e.g., Foley) is routinely performed for planned and emergency CD in most countries around the world. The drainage tube is inserted when analgesia is established and is then left in situ for 12 to 24 hours until the patient is able to mobilize. This tube is connected to a closed collection system to evacuate urine and decompress the urinary bladder. This may improve visualization of the lower uterine segment, which could minimize bladder injury. However, one RCT has shown that the incidence of urinary tract infection, time to patient ambulation, time to first postoperative voiding, requirement for oral rehydration, intestinal movement, and duration of hospital stay are all significantly reduced in the uncatheterized group with no increase in intraoperative complications or urinary retention. It should be noted that the study was not powered to assess for differences in bladder or ureteral injury. Alternatively, immediate postoperative removal of a urethral catheter after planned CD may be associated with a lower risk of urinary infection, although the difference was nonsignificant. Urinary bladder catheterization for CD is prudent until evidence can delineate that eliminating this practice will not result in an increase in bladder or ureteral injury. For those who choose not to place an indwelling catheter for CD, the patient should void immediately prior to the operation. Indwelling catheter placement in hemodynamically unstable women is recommended to monitor urine output and evaluate fluid balance.
Site Preparation
Preparation of the skin is performed to reduce the risk for wound infection by decreasing the amount of skin flora and contaminants at the incision site. Hair does not have to be removed from the operative site. Removal with a razor may actually increase the risk for infection by breaks in the skin that allow entry of bacteria. For this reason, some advocate clipping of the hair on the morning of surgery. Only enough hair should be removed to allow good approximation of skin edges.
Incision-site preparation is accomplished in the operating room through application of a surgical scrub. CD wounds are considered to be clean contaminated. Chlorhexidine-alcohol scrub has been associated with a lower incidence of wound infection compared with povidone-iodine scrub. In addition, drapes should not be adhesive because such drapes have been associated with a higher rate of wound infection compared with nonadhesive drapes.
Abdominal Skin Incision and Abdominal Entry
In general, universally accepted good surgical techniques aimed at avoiding excessive blood loss and tissue trauma should be used. Compared with sharp needles, the use of blunt needles during CD is associated with a decrease in the rate of surgeon glove perforation but also with a decrease in surgeon satisfaction.
The surgeon has a choice of a transverse or vertical skin incision, with the transverse Pfannenstiel being the most common incision type in the United States ( Fig. 19-2 ). Factors that influence the type of incision include the urgency of the delivery, placental disorders such as anterior complete placenta previa and placenta accreta, prior incision type, and the potential need to explore the upper abdomen for nonobstetric pathology. Although some still prefer a vertical incision in emergency situations, a Pfannenstiel incision actually adds only 1 minute of extra operative time in primary and 2 minutes in repeat cesareans, differences that are not associated with improved neonatal outcome compared with that of a vertical incision. Vertical incisions have been performed very rarely in the United States and Europe for routine CDs since the 1980s. A survey of obstetricians in the United Kingdom found that more than 80% use the Pfannenstiel abdominal entry. The remaining 20% use the incision and abdominal entry described by Joel-Cohen. A survey of obstetric residents in the United States found that 77% use a horizontal skin incision for urgent or emergency CD. Overall, the Pfannenstiel incision is currently the preferred technique around the world and is used for more than 90% of CDs in the United States. The Joel-Cohen incision was described for gynecologic surgical procedures such as abdominal hysterectomy, and it allows similar access to the pelvis and lower abdomen as a vertical incision but is more cosmetic and less painful postoperatively. In the early 1990s, the Joel-Cohen incision ( ) was integrated by Stark and colleagues into a minimalist cesarean technique now called the Misgav Ladach method . Thus far, studies reporting the benefits of the Joel-Cohen incision include multiple aspects of the CD technique, not just the skin incision ; therefore they are not clinically helpful in determining the benefit of the individual CD steps. Given this, we do not recommend the Joel-Cohen incision over the Pfannenstiel cesarean technique. For most repeat CDs, the prior skin incision is used. Transverse skin incisions are preferable to vertical incisions (see Table 19-1 ).
