Review the steps in a cesarean and take a moment to examine the best available evidence for performing the procedure.
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.
Cesarean sections are associated with a 10-fold increased risk of infection as compared to vaginal delivery.2 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.
The C-SOAP trial9 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/m2 or absolute weight of more than 100 kg.8
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.12 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.13
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.14
A Cochrane review in 2008 found higher rates of endometritis, blood loss, and greater drops in hematocrit with manual extraction.16
Single-layered closure has consistently shown beneficial results for short-term outcomes such as decreased blood loss, operative time, and postoperative pain.17 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,20 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.21
Randomized trials in obstetrics have not demonstrated benefit when used at time of cesarean delivery.22,23
A meta-analysis performed in 2004, subcutaneous tissue should be closed if the thickness is greater than 2 cm.24 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