In the United States, if not worldwide, a cesarean delivery is the most commonly performed abdominal operation and except for cataract surgery, the most commonly performed procedure in medicine.¹ The estimates are that in 2018 there will be approximately 1,300,000 cesarean deliveries in the United States and 30 million worldwide. To put these numbers in perspective, the current estimate is that there is one cesarean section performed every second somewhere in the world.² There are two aspects of this procedure, which lead to a somewhat cavalier attitude toward the potential complications which may arise. As in the concept that “familiarity often breeds contempt,”such a frequently performed operation is all too often taken for granted as being routine. The other influencing issue is that the procedure in its basic form is not complicated. In some ways, it is not an operation at all, but essentially an open and close process. In the standard case, it is a matter of entering several layers—skin, subcutaneous fat, fascia, peritoneum, uterus—removing an infant without requiring any surgical maneuvers, and then closing all the layers in proper sequence. It does not require any operative manipulations, such as removing a gall bladder or an appendix or a uterus, once the layers are open.

In the operative suite, the instrumentation required is minimal, and all too frequently, the C-section tray is significantly sparser than a hysterectomy tray in the same hospital. Many, if not most, hospitals have a hysterectomy tray readily available in Labor and Delivery, but this does not hold true for all obstetric operative suites around the country.

The most important prerequisite for the safe and efficacious performance of any surgical procedure or intervention is proper preparation. Obvious components include an understanding of the indications for the procedure, the goals of therapy, the potential pitfalls and complications which may be encountered during the procedure, and the immediate postprocedure and long-term consequences.³ Inherent in preparation is having the proper tools to accomplish the tasks, which also implies the knowledge and training with the use of such tools. Expanding on the old adage, “if your only tool is a hammer, everything appears like a nail” we can say, “if the only tool with which you are comfortable using is a hammer, then everything to you will look like a nail.”

The single most important approach in adequately preparing the operating suite for the difficult cesarean section is to first and foremost realize that the team is not dealing with the standard open-and-close cesarean section, but a pelvic and an abdominal operation which could potentially be as complex as a pelvic exenteration or an abdominal/perineal resection. Whatever mental and resource preparations are required for those complex surgical operations, the same preparation is required for the difficult cesarean delivery.

The operating room space should be adequate space to accommodate the multimember team. If an accreta is known beforehand, the procedure should probably be scheduled in a main OR suite. The operating tables should be adequate to accommodate possibly multiple “scrubbed” surgeons and technicians, and patients with a high body mass index (BMI). Lighting is critical, and personal head lamps may be necessary. Communication systems with potential intraoperative consultants should be in working order. The anesthesia team should be comfortable with management of rapid fluid changes, possible requirement of massive transfusion therapy, the management of central monitoring, and prolonged anesthesia times, as a minimum.

Below is a list of equipment and instruments required in a cesarean tray. This standard cesarean tray is more than adequate to enable the obstetrician to perform the procedure safely and expeditiously. In most cesarean delivery procedures, most of these instruments would be superfluous. However, in a difficult case, this list would be inadequate and needs expansion to include other instruments and equipment as described below (Figure 13-1).

To the above list, the following must be added with description of when and why they are needed. The first components would be essentially the same as those found in a standard hysterectomy tray (Figure 13-2).