Shelby M. Dickison, MD

Cesarean section is the most commonly performed surgical procedure in the United States, with nearly 1.3 million cases performed each year, approximately 32% of all deliveries.

 The purpose of this article is to review the steps in a cesarean delivery and examine the best available evidence for performing the procedure.

Cesarean sections are associated with a 10-fold increased risk of infection as compared to vaginal delivery.

In general, CHG-alcohol solutions have been shown to decrease SSI rates in a variety of surgeries; based on these studies and the results of Tuuli’s trial, CHG-alcohol skin preps are a reasonable first choice for obstetrical patients.

Several large studies evaluating antibiotic prophylaxis administered after cord clamping versus at the time of skin incision, however, found a reduced incidence of infectious morbidity when antibiotics were given within the 60 minutes preceding the skin incision.

Cefazolin, a first-generation cephalosporin, is most commonly chosen.  A combination of clindamycin and an aminoglycoside can be used for women with significant penicillin allergies.

 was a multicenter study that randomized 2013 women undergoing cesarean delivery during labor or after membrane rupture to an additional 500 mg azithromycin or placebo to their standard antibiotic prophylaxis. 

Given the different pharmacokinetics in obese women, a higher dose of antibiotics may be indicated in women with body mass index greater than 30 kg/m

 or absolute weight of more than 100 kg.

The Joel-Cohen technique was found to decrease all of the following when compared to the Pfannenstiel incision: time to delivery, overall operating room time, blood loss, and postoperative pain medication requirements.

 There were no differences regarding wound infection, blood transfusions or muscle strength 3 months after delivery. 

In clinical trials with modern antibiotic use, however, routine creation of a bladder flap has not demonstrated any benefit, although it does increase operative time.

Typically, hysterotomy is created in a transverse fashion through the lower uterine segment, given the increased risk of uterine rupture associated with classical cesareans. After uterine entry, the hysterotomy may be extended bluntly or sharply, most often with bandage scissors. Blunt dissection has been found to result in a quicker extension, less risk of inadvertent neonatal injury, and lower blood loss.

A Cochrane review in 2008 found higher rates of endometritis, blood loss, and greater drops in hematocrit with manual extraction.

Single-layered closure has consistently shown beneficial results for short-term outcomes such as decreased blood loss, operative time, and postoperative pain.

In a setting where vaginal birth after cesarean (VBAC) is uncommon, a single-layer closure is likely adequate, but the authors recommend a double-layer closure in a patient considering VBAC in the future. 

While observational studies suggest that closure of the parietal peritoneum may play a role in adhesion prevention,

 prospective studies randomizing patients to closure versus non-closure of the parietal peritoneum do not seem to show a benefit when adhesions are evaluated at the time of subsequent cesarean delivery.

Randomized trials in obstetrics have not demonstrated benefit when used at time of cesarean delivery.

A meta-analysis performed in 2004, subcutaneous tissue should be closed if the thickness is greater than 2 cm.

 That analysis demonstrated a 34% decreased risk of wound disruption when subcutaneous tissue greater than 2 cm was closed. The subcutaneous tissue may be closed with either a continuous suture or interrupted sutures, based on the surgeon’s preference

Martin JA, Hamilton BE, Osterman MJ. Births in the United States, 2015. Natl Center Health Stat Data Br. 2016;2015:1-8.  

Burrows LJ, Meyn LA, Weber AM.  Maternal morbidity associated with vaginal versus cesarean delivery.  Obstet Gynecol. 2004;May103(5 Pt 1):907-12.

Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2012 Feb 20;2:CD004985.

Huang H, Li G, Wang H, He M.  Optimal skin antiseptic agents for prevention of surgical site infection in cesarean section: a meta-analysis with trial sequential analysis.  J Matern Fetal Neonatal Med. 2017;Aug 30:1-8.

Tuuli MG, Liu J, Stout MJ, et al.  A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med. 2016;374(7):1-9.

Haas DM, Morgan S, Contreras K.  Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.  Cochrane Database Syst Rev. 2014;Dec 21(12CD007892).

Caissutti C, Saccone G, Zulio F, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis.  Obstet Gynecol. 2017;130(3):527-538.

ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472-83. 

Tita AT, Szychowski JM, Boggess K, et al  and C/SOAP Trial Consortium.  Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med. 2015;375(13):1231-41.

Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis:  a cost-effectiveness analysis. Obstet Gynecol. 2017;130(6):1279-84.

Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery. BJOG. 1999;106:221-226.

Mathai M, Hofmeyr GH, Mathai NE. Abdominal surgical incisions for caesarean section.  Cochrane Syst Rev. 2013;May 31;(5):CD004453. 

Tuuli MG, Odibo AO, Gogertey P, Roehl K, Stamilio D, Macones GA.  Utility of the bladder flap at cesarean delivery: a randomized controlled trial.  Obstet Gynecol. 2012;119(4):815-21.

Magann EF, Chauhan SP, Bufkin L, Field K, Roberst WE, Martin JN Jr. Intra-operative Haemorrhage by blunt versus sharp expansion of the uterine incision at cesarean delivery: a randomized clinical trial. BJOG. 2002;109(4):448-52.

Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol. 2008;199(3):292 e1-6.

Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section.  Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737.

Dodd JM, Anderson ER, Gates S, Grivell RM.  Surgical techniques for uterine incision and uterine closure at the time of cesarean section.  Cochrane Database Syst Rev. 2014 Jul 22;(7):CD004732.

Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL.  Single- versus double-layer uterine incision closure and uterine rupture.  J Matern Fetal Neonatal Med. 2006;19(10):639-43.

Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet. 2011;115(1):5-10.

Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions.  Obstet Gynecol. 2005;106(2):275-80.

Kapustian V, Anteby EY, Gdalevich M, Shenhav S, Lavie O, Gemer O. Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study. Am J Obstet Gynecol. 2012;206(1):56.e1-4.

Kiefer DG, Muscat JC, Santorelli J, et al. Effectiveness and short-term safety of modified sodium hyaluronic acid-carnoxymethylcellulose at cesarean delivery: a randomized trial. Obstet Gynecol. 2016;214(3):373.e1-373.e12.

Gaspar-Oishi M Aeby T.  Cesarean delivery times and adhesion severity associated with prior placement of a sodium hyaluronate-carboxycellulose barrier.  Obstet Gynecol. 2014;124(4):679-83.

Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol. 2004;103(5 Pt 1):974-80.

Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing a cesarean delivery. Obstet Gynecol. 2005;105(5 Pt 1):967-73.

Figueroa D, Jauk VC, Szychowski JM et al. Surgical staples compared with subcuticular suture for skin closure after cesarean delivery: a randomized controlled trial.  Obstet Gynecol. 2013;121(1):33-8.

Mackeen AD, Schuster M, Berghella V.  Suture versus staples for skin closure after cesarean section: a metaanalysis. Am J Obstet Gynecol. 2015;212(5):621.e1-10.

Buresch AM, Van Arsdale A, Ferzli, M,  et al. Comparison of subcuticular suture type for skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2017;130(3):521-26.

Yu L, Kronen RJ, Simon LE, Stoll CRT, Colditz GA, Tuuli MG.  Prophylactic negative-pressure wound therapy after cesarean is associated with reduced risk of surgical site infection: a systematic review and meta-analysis. Am J Obstet Gynecol. 2017;Sep 23.pii: S0002-9378(17)31132-8.[Epub ahead of print].

Articles

Review the steps in a cesarean and take a moment to examine the best available evidence for performing the procedure.

Evidence-based cesarean delivery guidelines

Cesarean section is the most commonly performed surgical procedure in the United States, with nearly 1.3 million cases performed each year, approximately 32% of all deliveries.1 The purpose of this article is to review the steps in a cesarean delivery and examine the best available evidence for performing the procedure.

1.	 Martin JA, Hamilton BE, Osterman MJ. Births in the United States, 2015. Natl Center Health Stat Data Br. 2016;2015:1-8.   2.	Burrows LJ, Meyn LA, Weber AM.  Maternal morbidity associated with vaginal versus cesarean delivery.  Obstet Gynecol. 2004;May103(5 Pt 1):907-12.3.	Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2012 Feb 20;2:CD004985.4.	Huang H, Li G, Wang H, He M.  Optimal skin antiseptic agents for prevention of surgical site infection in cesarean section: a meta-analysis with trial sequential analysis.  J Matern Fetal Neonatal Med. 2017;Aug 30:1-8.5.	Tuuli MG, Liu J, Stout MJ, et al.  A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med. 2016;374(7):1-9.6.	Haas DM, Morgan S, Contreras K.  Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.  Cochrane Database Syst Rev. 2014;Dec 21(12CD007892).7.	Caissutti C, Saccone G, Zulio F, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis.  Obstet Gynecol. 2017;130(3):527-538. 8.	ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472-83.  9.	Tita AT, Szychowski JM, Boggess K, et al  and C/SOAP Trial Consortium.  Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med. 2015;375(13):1231-41.10.	 Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis:  a cost-effectiveness analysis. Obstet Gynecol. 2017;130(6):1279-84.11.	Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery. BJOG. 1999;106:221-226.12.	Mathai M, Hofmeyr GH, Mathai NE. Abdominal surgical incisions for caesarean section.  Cochrane Syst Rev. 2013;May 31;(5):CD004453.  13.	Tuuli MG, Odibo AO, Gogertey P, Roehl K, Stamilio D, Macones GA.  Utility of the bladder flap at cesarean delivery: a randomized controlled trial.  Obstet Gynecol. 2012;119(4):815-21. 14.	Magann EF, Chauhan SP, Bufkin L, Field K, Roberst WE, Martin JN Jr. Intra-operative Haemorrhage by blunt versus sharp expansion of the uterine incision at cesarean delivery: a randomized clinical trial. BJOG. 2002;109(4):448-52.15.	Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol. 2008;199(3):292 e1-6.16.	Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section.  Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737.17.	Dodd JM, Anderson ER, Gates S, Grivell RM.  Surgical techniques for uterine incision and uterine closure at the time of cesarean section.  Cochrane Database Syst Rev. 2014 Jul 22;(7):CD004732.18.	Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL.  Single- versus double-layer uterine incision closure and uterine rupture.  J Matern Fetal Neonatal Med. 2006;19(10):639-43. 19.	Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet. 2011;115(1):5-10.20.	Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions.  Obstet Gynecol. 2005;106(2):275-80. 21.	Kapustian V, Anteby EY, Gdalevich M, Shenhav S, Lavie O, Gemer O. Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study. Am J Obstet Gynecol. 2012;206(1):56.e1-4. 22.	Kiefer DG, Muscat JC, Santorelli J, et al. Effectiveness and short-term safety of modified sodium hyaluronic acid-carnoxymethylcellulose at cesarean delivery: a randomized trial. Obstet Gynecol. 2016;214(3):373.e1-373.e12.23.	Gaspar-Oishi M Aeby T.  Cesarean delivery times and adhesion severity associated with prior placement of a sodium hyaluronate-carboxycellulose barrier.  Obstet Gynecol. 2014;124(4):679-83.24.	Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol. 2004;103(5 Pt 1):974-80.25.	Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing a cesarean delivery. Obstet Gynecol. 2005;105(5 Pt 1):967-73.26.	Figueroa D, Jauk VC, Szychowski JM et al. Surgical staples compared with subcuticular suture for skin closure after cesarean delivery: a randomized controlled trial.  Obstet Gynecol. 2013;121(1):33-8.27.	Mackeen AD, Schuster M, Berghella V.  Suture versus staples for skin closure after cesarean section: a metaanalysis. Am J Obstet Gynecol. 2015;212(5):621.e1-10.28.	Buresch AM, Van Arsdale A, Ferzli, M,  et al. Comparison of subcuticular suture type for skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2017;130(3):521-26. 29.	Yu L, Kronen RJ, Simon LE, Stoll CRT, Colditz GA, Tuuli MG.  Prophylactic negative-pressure wound therapy after cesarean is associated with reduced risk of surgical site infection: a systematic review and meta-analysis. Am J Obstet Gynecol. 2017;Sep 23.pii: S0002-9378(17)31132-8.[Epub ahead of print]. 