Cesarean delivery: Preoperative issues

Author
Vincenzo Berghella, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD
Disclosures: Vincenzo Berghella, MD Nothing to disclose. Charles J Lockwood, MD, MHCM Nothing to
disclose. Vanessa A Barss, MD Employee of UpToDate, Inc. Equity Ownership/Stock Options: Merck; Pfizer;
Abbvie.
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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jul 2014. | This topic last updated: Aug 06, 2014.
INTRODUCTION Cesarean delivery (also called cesarean section and cesarean birth) refers
to the delivery of a baby through surgical incisions in the abdomen and uterus. Cesarean
deliveries are categorized as either primary (ie, first cesarean delivery) or repeat (ie, after a
previous cesarean birth). The total cesarean delivery rate is the sum of these two components.
The cesarean delivery rate worldwide is about 15 percent of births [1]. The mean cesarean
delivery rate in developed countries is 21.1 percent, but only 2 percent in the least developed
countries. A World Health Organization (WHO) survey of 122 facilities in nine Asian countries
reported an overall rate of cesarean delivery of 27.3 percent [2]. A similar WHO survey of eight
Latin American countries observed an overall cesarean delivery rate of 35.4 percent [3].
In the United States, over one million cesarean deliveries are performed annually and accounted
for 32.8 percent of United States births in 2011 [4]. Worldwide, Mexico, Brazil, Italy, Iran,
Argentina, Dominican Republic, Cuba, and Korea have the highest rates (over 35 percent) and
Africa has the lowest (under 5 percent) [5]. In Brazil, the wealthiest 10 percent of women have a
cesarean delivery rate of 77 percent [6]. The cesarean delivery rate in China ranges from 20 to 60
percent, depending on whether the hospital is rural or urban [7-9]. The cesarean rate was 25
percent in teaching hospitals in India [10], but 8.5 percent overall [5].
This topic will review preoperative issues relating to cesarean delivery. Surgical technique,
postoperative issues, repeat cesarean delivery, and trial of labor after cesarean delivery are
discussed separately:
(See "Cesarean delivery: Technique".)
(See "Cesarean delivery: Postoperative issues".)
(See "Repeat cesarean delivery".)
(See "Choosing the route of delivery after cesarean birth".)
INDICATIONS AND CONTRAINDICATIONS Cesarean delivery is performed when the
clinician and patient feel that abdominal delivery is likely to provide a better maternal and/or fetal
outcome than vaginal delivery. The term "elective cesarean delivery" should probably be
eliminated because a cesarean delivery is either "medically/obstetrically indicated" or "on
maternal request," and never truly "elective." Cesarean delivery on maternal request is discussed
separately. (See "Cesarean delivery on maternal request".)
The decision to perform an indicated cesarean delivery may be made antepartum or as a result of
concerns identified after labor has begun ("unscheduled cesarean delivery" or "unplanned
cesarean delivery"). The terms "scheduled cesarean delivery" or "planned cesarean delivery" are
used when the decision to perform a cesarean delivery does not occur as a consequence of a
complication of labor, but is planned antepartum, such as in the case of repeat cesarean delivery,
fetal malpresentation, or placenta previa.
Approximately 70 percent of cesarean deliveries in the United States are primary (first)
cesareans. The three most common indications for primary cesarean delivery in the United States
account for almost 80 percent of these deliveries [11]:
Failure to progress during labor (35 percent)
Nonreassuring fetal status (24 percent)
Fetal malpresentation (19 percent)
Additional, less common indications for cesarean delivery include, but are not limited to:
Abnormal placentation (eg, placenta previa, vasa previa, placenta accreta)
Maternal infection (eg, herpes simplex or human immunodeficiency virus)
Multiple gestation
Fetal bleeding diathesis
Funic presentation or cord prolapse
Suspected macrosomia (5000 grams in women without diabetes, 4500 grams in women
with diabetes)
Mechanical obstruction to vaginal birth (eg, large leiomyoma or condyloma acuminata,
severely displaced pelvic fracture, fetal anomalies such as severe hydrocephalus)
Uterine rupture
(See individual topic reviews on each subject).
Cesarean delivery may also be indicated in women who are at increased risk of complications
from tissue trauma related to cervical dilation, the descent and expulsion of the fetus, or
episiotomy. Some examples include women with invasive cervical cancer or active perianal
inflammatory bowel disease, and those who have undergone repair of a rectovaginal fistula or
pelvic organ prolapse. (See "Fertility, pregnancy, and nursing in inflammatory bowel
disease" and "Urinary incontinence and pelvic organ prolapse associated with pregnancy and
childbirth" and "Fecal incontinence associated with pregnancy and childbirth" and "Cervical
cancer in pregnancy".)
Cesarean delivery may be performed, but is not routinely indicated for fetal issues, such as
extremely or very low birth weight (<1000 g and 1500 g, respectively) [12], or certain congenital
anomalies (eg, open neural tube defects, some skeletal dysplasias, and gastroschisis with
herniated liver) [13,14]. We do not recommend cesarean delivery for these indications.
(See "Intrapartum management of the low birthweight vertex fetus" and "Overview of the
management of myelomeningocele (spina bifida)" and "Obstetrical management of
gastroschisis" and "Obstetrical management of omphalocele".)
There are no absolute contraindications to cesarean delivery. In contrast to other types of
surgery, the risks and benefits of the procedure need to be considered as they apply to two
patients (mother and fetus). However, many pregnant women have a low tolerance for accepting
any fetal risk from vaginal birth, irrespective of the maternal risks associated with operative
intervention [15,16].
PREOPERATIVE ISSUES Checklists can be helpful in preoperative assessment, and are
available from various organizations, such as the American College of Obstetricians and
Gynecologists (ACOG) [17,18].
Assessment of fetal pulmonary maturity Planned term cesarean delivery should be
scheduled for 39 weeks of gestation [19]. Fetal pulmonary maturity can be inferred if:
Review of the patient's prenatal record confirms a gestational age of 39 weeks of
gestation. (See "Prenatal assessment of gestational age and estimated date of delivery".)

or
Tests on amniotic fluid suggest a low risk of neonatal respiratory distress. However, testing
is only indicated in women of uncertain gestational age. Testing to confirm pulmonary
maturity in order to proceed with a planned delivery before 39 weeks should generally be
avoided. (See "Assessment of fetal lung maturity".)
Data from large observational studies have consistently shown that neonatal respiratory
morbidity and/or composite neonatal morbidity is higher after scheduled cesarean delivery than
vaginal delivery, but decreases as gestational age increases from 37 to 39 weeks [20-29]. As an
example, a large trial evaluated respiratory morbidity (eg, respiratory distress syndrome, transient
tachypnea of the newborn) in over 34,000 term infants delivered without prior assessment of fetal
lung maturity [22]. Compared with infants of women who intended to have a vaginal delivery,
those delivered by scheduled cesarean delivery had a significantly increased risk of respiratory
morbidity at any gestational age before 40 weeks: 37 weeks (OR 3.9, 95% CI 2.4-6.5; 10 versus
2.8 percent), 38 weeks (OR 3.0, 95% CI 2.1-4.3; 5.1 versus 1.7 percent), 39 weeks (OR 1.9, 95%
CI 1.2-3.0; 2.1 versus 1.1 percent), 40 weeks (OR 0.9, 95% CI 0.2-3.7; 1.5 versus 1.6 percent)
[22]. In a randomized trial of planned cesarean delivery at 38
3/7ths
versus 39
3/7ths
weeks of
gestation, the group delivered at 39
3/7ths
weeks had a lower rate of respiratory morbidity (6.8
versus 9.0 percent, RR 0.75, 95% CI 0.51-1.10) and neonatal intensive care unit (NICU)
admission within 48 hours of birth (11.9 versus 13.9 percent, RR 0.86, 95% CI 0.65-1.15) [30].
This trial may have been underpowered (n = 1272 infants) to detect a statistically significant
reduction in these outcomes. (See "Cesarean delivery on maternal request", section on
'Increased risk of respiratory problems in offspring'.)
The risks of iatrogenic early term birth (37 to 38 weeks) appear to outweigh any theoretical
benefits when the indication for delivery is "soft," such as suspected macrosomia without
maternal diabetes or history of fetal, maternal, or obstetric complication in a previous pregnancy.
Anesthesia As with any surgical procedure, women undergoing cesarean delivery should
have a preoperative anesthesiology consultation. Those whose procedure-related risks are above
baseline should have a preadmission consultation with an anesthesiologist. Characteristics that
place the patient at increased risk include, but are not limited to, those listed in the table (table 1).
The choice of regional or general anesthesia is influenced by factors such as the urgency of the
procedure, maternal status, and physician and patient preference. Issues related to anesthesia
for cesarean delivery are discussed separately. (See "Anesthesia for cesarean delivery".)
Laboratory testing A baseline hemoglobin measurement is recommended in patients who are
undergoing major surgery, such as cesarean delivery, that is expected to result in significant
blood loss. A normal value obtained within one month of surgery probably does not need to be
repeated preoperatively in uncomplicated pregnancies. (See "Preoperative medical evaluation of
the healthy patient".)
Pregnant women generally have a blood type and antibody screen performed as part of routine
prenatal care. A repeat type and screen preoperatively probably can be safely omitted in women
at low-risk of hemorrhagic complications during surgery and who do not have a known red blood
cell antibody [31-35]. Fewer than 1 percent of such women receive a perioperative blood
transfusion. Risk factors for transfusion include: placental abnormalities (eg, previa, accreta, or
abruption), eclampsia or HELLP syndrome (ie, Hemolysis, Elevated Liver function tests, Low
Platelets), preoperative hematocrit less than 25 percent, general anesthesia, and a history of five
or more cesarean deliveries. Alternatively, the surgeon may consider a "hold clot" order in low-
risk patients: blood is drawn and held, but no tests are performed unless clinically indicated.
Antibiotic prophylaxis To reduce the risk of postoperative infection, a single intravenous
dose of a narrow spectrum antibiotic (eg, cefazolin) should be administered preoperatively to all
women undergoing cesarean delivery [36,37].
The benefit of antibiotic prophylaxis was illustrated in a systematic review of 86 randomized trials
that compared infection outcomes after both scheduled and "in labor" cesarean delivery with or
without the use of prophylactic antibiotics [37]. Antibiotic prophylaxis significantly reduced the
incidence of postoperative fever, endometritis, wound infection, urinary tract infection, and serious
maternal infectious complications compared to controls receiving no antibiotic treatment. The
relative risk of endometritis was reduced by approximately 60 percent after scheduled cesarean
delivery, "in labor" cesarean delivery, and for all patients (relative risk = 0.39, 0.40, and 0.36,
respectively). None of the studies reported on infant outcomes, such as short- and long-term
adverse effects, oral thrush, effects on immune system development, and development of
bacterial resistance. A subsequent analysis found no increase in neonatal infectious illness or
selection of antimicrobial-resilient bacteria causing neonatal sepsis; however, the studies were
underpowered and did not allow a clear conclusion [38].
Although the relative risk reduction in maternal infection is statistically significant and similar for
both scheduled and in labor procedures, the absolute risk of maternal infection is quite low in
scheduled cases (postpartum endometritis 2 percent with antibiotic prophylaxis, 2.6 percent
without antibiotic prophylaxis; wound infection 0.52 percent with antibiotic prophylaxis, 0.96
percent without antibiotic prophylaxis [39]). Looked at in another way, 1000 women undergoing
scheduled cesarean would receive antibiotics to prevent 6 cases of endometritis and 4.4 cases of
abdominal wound infection. The low risk of maternal infection in these cases and uncertainty
about long-term effects in offspring has prompted a call for more research on potential long-term
risks of exposure to antibiotic prophylaxis and strategies for risk stratification to identify the best
candidates for antibiotic prophylaxis [40].
Choice of drug and dose Comparative trials do not provide strong evidence on which to base
a recommendation for the optimal type and dose of antibiotic. In a 2010 systematic
review, cefazolin and ampicillin appeared to be similarly effective [41]. A guideline developed
jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases
Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare
Epidemiology of America (SHEA) recommends 2 grams cefazolin for patients <120 kg and 3
grams for patients 120 kg (table 2) [42]; the Medical Letter suggests 1 gram for patients <80 kg
and 2 grams for those 80 kg [43]. We use cefazolin 2 grams in patients <120 kg, as this dose
has an excellent safety profile and, in one study, 20 percent of obese (body mass index [BMI] 30
to 39.9 kg/m
2
) and extremely obese women (BMI 40 kg/m
2
) did not achieve minimal inhibitory
concentrations for Gram-negative rods in adipose samples at skin incision even with a 2 gram
dose [44].
There are few data comparing these drugs against extended spectrum antibiotic combinations
(eg, gentamicin and ampicillin, cefazolin and metronidazole, azithromycin and doxycycline and ce
fotetan) [45].
One randomized trial that evaluated this issue reported lower endometritis and wound
infection rates when extended spectrum antibiotics were administered after surgery in
addition to surgical prophylaxis. In this trial, 597 women undergoing scheduled and
unscheduled cesarean deliveries received cefotetan (2 g) at cord clamping and then were
randomly assigned to receive doxycycline (100 mg intravenously at cord clamping) followed
by azithromycin (1 g orally) 6 to 12 hours later or placebo (at cord clamping and again
postoperatively) [46].

Extended spectrum antibiotic prophylaxis continued after surgery was associated with a
significant reduction in postpartum endometritis (16.9 versus 24.7 percent) and wound
infection (0.8 versus 3.6 percent). Follow-up observational studies by the same group
affirmed these findings [47,48]. The authors postulated that these results were due to
coverage against Ureaplasma urealyticum provided by the extended antibiotic regimen.
However, since no cultures were performed, a different mechanism may have accounted for
the reduction in postoperative infection.
We would like to see confirmatory data from randomized trials at other institutions before
recommending use of extended spectrum antibiotic prophylaxis, given the higher cost of these
drugs and the potential increase in antibiotic resistant infection with this approach. It is possible
that a subset of high risk women may benefit from extended spectrum antibiotics; this needs to be
investigated in appropriately designed trials. Prophylaxis against ureaplasmas is unlikely to be
important since clinical endometritis generally responds to antibiotic treatments that do not cover
this organism. It would also be appropriate to evaluate one-time dosing (at the time of surgery) of
broad spectrum antibiotics versus a standard antimicrobial (eg, cephalosporin) in a clinical trial
setting before instituting a broad-spectrum regimen, as the trials above may have been affected
by the continuation of antibiotics after the surgery.
We avoid use of amoxicillin-clavulanic acid because of concerns raised about its safety. In a 2013
meta-analysis of placebo-controlled randomized trials of antibiotic therapy in women with preterm
rupture of membranes, use of amoxicillin-clavulanic acid appeared to be associated with a
significant increase in the number of babies who developed necrotizing enterocolitis (RR 4.72,
95% CI 1.57-14.23; two trials: 29/1236 versus 3/613) [49]. The wide confidence interval shows
that these findings need to be confirmed by larger studies; in the meantime, we avoid its use
since safe and effective alternatives are available.
Penicillin allergy For women with a history of serious penicillin allergy (immediate
hypersensitivity reaction), we suggest combination therapy with clindamycin (900 mg [42])
plus gentamicin (5 mg/kg [42]) intravenously, which provides broad coverage [42,50]. Guidelines
developed jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious
Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for
Healthcare Epidemiology of America (SHEA) recommend clindamycin (900 mg) and an
aminoglycoside (gentamicin or tobramycin) in women with beta-lactam allergy (table 2) [42].
When gentamicin is used for prophylaxis in combination with a parenteral antimicrobial with
activity against anaerobic agents, they advise 4.5 to 5 mg/kg of gentamicin as a single dose as
many studies support the safety and efficacy of this dose when used as a single dose for
prophylaxis in patients without renal insufficiency, and a trial of antibiotic prophylaxis in colorectal
surgery reported this dose may be more effective than multiple standard doses (1.5 mg/kg) in
prolonged operations [51]. However, cesarean delivery typically takes less than an hour, thus a
lower dose of gentamicin may be adequate; there are no comparative dosing trials in this
population.
A cephalosporin can be given to patients at low risk of a serious IgE-mediated reaction. The risk
of a penicillin-allergic patient reacting to a cephalosporin may be assessed based upon the
results of penicillin skin testing (if available), the clinical features of the penicillin reaction, and the
time elapsed since the last reaction to penicillin (algorithm 1). (See "Penicillin-allergic patients:
Use of cephalosporins, carbapenems, and monobactams" and "Allergy to penicillins".)
Number of doses We use a single dose regimen, given that a systematic review of
randomized trials showed that single dose regimens were as effective as multiple dose regimens
[52] and single dose regimens are the standard. However, some data (see above) suggest that
continuation of a broad-spectrum regimen for 6 to 12 hours postoperatively may decrease
infectious morbidity [46-48].
Timing Antimicrobial therapy should be administered within 60 minutes before making the skin
incision to ensure adequate drug tissue levels [50]. (See "Antimicrobial prophylaxis for prevention
of surgical site infection in adults", section on 'Timing'.)
This recommendation is supported by a meta-analysis of randomized trials that compared
infection rates in women assigned to a single preincision dose of antibiotic prophylaxis versus
those assigned to administration after cord clamping [38]. Preincision prophylaxis was
significantly more effective than delayed administration for prevention of endometritis (RR 0.59,
95% CI 0.37-0.94) and was not associated with an increase in proven neonatal sepsis, sepsis
workups, or admission to the neonatal intensive care unit, although the trials had limited power to
detect adverse neonatal effects.
Delaying antibiotic administration until after cord clamping in an attempt to avoid interference with
neonatal cultures had been a common practice, but is not necessary and is no longer requested
by pediatricians [53,54].
Woman already on antibiotics For the woman in labor already receiving antibiotics for GBS
prophylaxis and later needing cesarean delivery, we do not add further antibiotic prophylaxis,
although others centers administer a single dose of a broad spectrum antibiotic (eg, cefazolin).
For the woman already receiving ampicillin and gentamicin for chorioamnionitis, we add one dose
of clindamycin, and continue ampicillin and gentamicin or switch to ampicillin-sulbactam until the
patient is afebrile for at least 24 hours. Bacteroides resistance to clindamycin is increasing; in
areas of high resistance, ampicillin-sulbactam is preferable.
There are no randomized trials assessing efficacy of antibiotic regimens in these clinical
scenarios.
Thromboembolism prophylaxis The risk of cesarean-associated thromboembolism is 0.23
percent [55] and more than 80 percent of fatal puerperal pulmonary embolisms occur after
cesarean delivery [56]. Currently, many obstetrical units in the United States provide mechanical
prophylaxis to all women undergoing cesarean delivery, and add pharmacologic prophylaxis
postpartum for women with additional risk factors. Unfractionated heparin or low molecular weight
heparin is started 6 to 12 hours after cesarean delivery if there is no significant bleeding.
(See "Overview of the causes of venous thrombosis".)
The value of thromboprophylaxis for cesarean delivery has not been studied in adequately
powered randomized clinical trials [57]. Cesarean delivery probably increases the risk of venous
thromboembolism (VTE); however, observational data suggest that the level of risk for clinically
important events is modest and similar to that seen in low risk surgical patients for whom no
routine thromboprophylaxis other than early ambulation is recommended.
Low-risk women We agree with the ACOGs recommendation to place pneumatic
compression devices on all patients not already receiving pharmacologic thromboprophylaxis
before cesarean delivery [58]. Observational studies of pregnant women suggest that pneumatic
compression devices, as well as compression stockings, are safe and effective [59,60]. We
continue pneumatic compression until the patient is fully ambulatory [61].
By comparison, the American College of Chest Physicians (ACCP) Evidence-Based Clinical
Practice Guidelines do not recommend prophylaxis (other than early ambulation postpartum) for
women whose only risk factors for VTE are pregnancy and cesarean delivery [62].
High-risk women We agree with the ACOGs recommendation for consideration of both
mechanical and pharmacological thromboprophylaxis in women undergoing cesarean delivery at
high risk of VTE [58]. These women may include those with BMI >50kg/m
2
, previous VTE, high-
risk thrombophilia (inherited or acquired), or two or more less prominent risk factors for VTE.
Unfractionated or low molecular weight heparin can be used; options include enoxaparin 40 mg
daily or unfractionated heparin 5000 every 12 hours. Pharmacologic prophylaxis is begun 6 to 12
hours postoperatively, after concerns for hemorrhage have decreased, and is continued until the
woman is fully ambulating [63]. However, there are no data from randomized trials to support or
refute this approach.
Pneumatic compression devices are left in place until the patient is ambulatory and until
anticoagulation therapy has been restarted [58].
The ACCP Evidence-Based Clinical Practice Guidelines recommend prophylaxis for women
undergoing scheduled cesarean delivery who have additional risk factors for VTE [62]:
Women with one additional major risk factor for VTE or two additional minor risk factors for
VTE should receive pharmacologic thromboprophylaxis while in the hospital following
delivery. If anticoagulants are contraindicated, graduated compression stockings or a
pneumatic compression device should be used.
Women with multiple additional risk factors for VTE should receive pharmacologic
thromboprophylaxis plus graduated compression stockings and/or pneumatic compression
devices while in the hospital following delivery.
According to the ACCP, major risk factors include strict bedrest for 1 week antepartum,
postpartum hemorrhage 1000 mLs at surgery, previous VTE, preeclampsia with fetal growth
restriction, antithrombin deficiency, factor V Leiden (homozygous or heterozygous), prothrombin
G20210A (homozygous or heterozygous), blood transfusion, infection, and some medical
conditions (lupus, heart disease, sickle cell disease). Minor risk factors include BMI
>30 kg/m
2
, multiple gestation, postpartum hemorrhage >1000 mL, smoking
>10 cigarettes/day, birth weight <25
th
centile, protein C or S deficiency, or preeclampsia. If the
cesarean delivery is performed emergently, the presence of only one minor risk factor is sufficient
to warrant VTE prophylaxis.
Others have also considered the following potential risk factors for VTE: malignancy, lower body
orthopedic cast, age over 35 years, and nephrotic syndrome [55,64-72].
The Royal College of Obstetricians and Gynaecologists (RCOG) and Society of Obstetricians and
Gynaecologists of Canada (SOGC) recommend pharmacologic thromboprophylaxis for women
with additional risk factors for VTE [73,74].
Fetal heart rate monitoring The fetal heart rate should be documented prior to cesarean
delivery. The value of continuous or intermittent fetal heart rate monitoring prior to scheduled
cesarean delivery in low risk women is unclear [75]. If possible, laboring patients who were
monitored in the labor room should continue to be monitored after transfer to the operating room
when surgery is significantly delayed. There are no randomized trials assessing the utility for
electronic fetal heart rate monitoring before cesarean delivery.
Fetal presentation and placental location An ultrasound for assessment of placental
location and fetal presentation, or Leopold maneuvers to assess fetal presentation, are probably
useful, but their effectiveness has not been prospectively studied in a randomized trial.
Bladder catheterization Most clinicians insert a urethral catheter at the start of the case to
maintain bladder drainage and thereby improve visualization during surgery and minimize bladder
injury. The catheter is also useful for instilling dye if a cystotomy is suspected and monitoring
urine output. Potential harms include an increased incidence of urinary tract infection, urethral
pain, voiding difficulties after removal of the catheter, delayed ambulation, and increased hospital
stay [76]. There is no strong evidence that routine placement of an indwelling catheter is
advantageous [76,77]. As an alternative, patients at low risk of intraoperative complications can
be asked to void shortly before the procedure, and an indwelling catheter can be inserted
intraoperatively or postoperatively if required, and removed as early as possible [78-81].
Hair removal A meta-analysis including 11 randomized controlled trials found no difference in
the rate of surgical site infection in non-pregnant patients who had hair removed prior to surgery
and those who did not [82]. There are no randomized trials assessing this intervention specifically
before cesarean delivery.
If hair needs to be removed, it should be clipped rather than shaved, as patients who are shaved
are more likely to develop surgical site infection. Use of a depilatory cream is also preferable to
shaving. Clipping should be performed just before surgery [83]. (See"Adjunctive measures for
prevention of surgical site infection in adults", section on 'Hair removal'.)
Skin preparation A large randomized trial (n = 849 subjects) found that preoperative
cleansing of the patient's skin with chlorhexidine-alcohol was superior to cleansing with povidone-
iodine for preventing surgical-site infection after clean-contaminated surgery [84]. The overall rate
of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the
povidone-iodine group (9.5 versus 16.1 percent, RR 0.59; 95% CI 0.41-0.85). Based on these
data, we prep the abdominal surgical site with a chlorhexidine-alcohol scrub before cesarean
delivery.
The benefit of bathing with an antiseptic preparation prior to surgery to reduce the risk of surgical
site infection is uncertain [85-88]. In a meta-analysis of six trials involving 10,007 participants,
preoperative bathing with chlorhexidine conferred no benefit over preoperative bathing with other
products for reduction of SSI [88].
These data were derived from trials in general surgical patients; less data are available for
patients undergoing cesarean delivery. A systematic review of trials performed in these patients
(5 trials, 1462 women) and using various techniques of skin preparation concluded there was
insufficient evidence to determine the optimal method [89].
Well-designed randomized trials are needed to determine whether one antiseptic is more
effective than another for preventing post-cesarean wound infection, whether other factors are
clinically more important than the type of antiseptic, and the comparative costs, risks, and
benefits of various antiseptics.
Vaginal antimicrobial preparations The addition of a vaginal povidone-iodine scrub to
abdominal skin cleaning before cesarean delivery was assessed in a meta-analysis of five
randomized trials [90]. Compared with abdominal preparation alone, the combination of
abdominal and vaginal preparation significantly reduced the frequency of post-cesarean
endometritis (RR 0.39, 95% CI 0.16-0.97; 3.6 versus 7.2 percent). This benefit was primarily
related to the large effect of this intervention in women with ruptured membranes (RR 0.13, 95%
CI 0.02-0.66; 1/70 versus 12 /78); vaginal preparation did not result in a statistically significant
reduction in endometritis in women with intact membranes. The rates of wound infection and
postoperative fever were not significantly reduced regardless of membrane status. However, this
meta-analysis failed to address the important confounder of how skin cleaning was performed.
Since we use a chlorhexidine-alcohol scrub before cesarean delivery (discussed above) and
administer prophylactic antibiotics, we do not believe there is any additional benefit to vaginal
preparation and do not perform it.
If vaginal preparation is desired, the ACOG have opined that either 4 percent chlorhexidine
gluconate with 4 percent isopropyl alcohol or povidone-iodine can be used [91].
The use of intravaginal antibiotics has also been evaluated, but data are
limited. Metronidazole gel (5 mg intravaginally before cesarean delivery) resulted in a decrease in
the incidence of postpartum endometritis, but no other significant effects [92].
Drapes The surgical site is draped with nonadhesive drapes, as they appear to be associated
with a lower rate of wound infection than adhesive drapes for cesarean delivery [93,94].
Uterine displacement The uterus is displaced at least 15 degrees to the left to reduce
aortocaval compression ("supine hypotensive syndrome") [95-99]. A foam or wood wedge, pillow,
or rolled blanket may be used, or the table can be tilted, or the uterus can be manually displaced.
A systematic review was not able to determine the optimum method or maternal position [100].
Perioperative management of medication (See "Perioperative medication management".)
EMERGENCY DELIVERY One-half to 1 percent of deliveries require emergency intervention
[101,102]. An emergency cesarean delivery is defined as a cesarean delivery that is performed
after labor has begun; by comparison, a scheduled or planned cesarean is performed before
labor has begun. Emergency cesareans are sometimes further classified by degree of urgency;
for example: (1) an immediate threat to life of the mother or fetus is present, (2) signs of maternal
or fetal compromise are present but are not immediately life threatening, or (3) delivery is needed
but there is no evidence of maternal or fetal compromise.
The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of
Pediatrics (AAP) have suggested that facilities providing obstetrical services should be capable of
beginning an emergency cesarean delivery within 30 minutes of the decision to perform the
operation [103]. This criterion is based upon the practical constraints most rural hospitals face in
assembling the appropriate team of nurses, anesthetists, and surgeons. However, this threshold
is not evidence-based, universally achievable, or ideal from the perspective of decreasing
perinatal mortality and morbidity [102,104-112].
The ability to begin an emergency cesarean delivery within 30 minutes of the decision to operate
is a reasonable benchmark for monitoring the quality of labor and delivery units; the statement
was not intended as a requirement that all cesarean deliveries be performed within 30 minutes of
the decision. In human and animal studies, sudden complete anoxia, such as occurs with a total
abruption or complete cord occlusion, probably necessitates delivery within five minutes to avoid
fetal hypoxic injury [113-115], although intact survivors have been reported after longer durations
of severe hypoxia. Most pregnancies with less severe fetal or maternal compromise or partial or
complete recovery of nonreassuring fetal heart rate tracings will have good outcomes despite
longer intervals before initiating surgery.
Compared with nonemergent cesarean delivery, emergency cesarean is associated with
increased risks of severe hemorrhage, anesthetic complications from rapid administration of
general anesthesia, and accidental injury to the fetus or abdominopelvic organs.
NATURAL, GENTLE, OR FAMILY-CENTERED CESAREAN The natural, gentle, or family-
centered cesarean delivery approach was developed to improve the birth experience of women
having uncomplicated cesarean deliveries. It attempts to replicate features of vaginal birth as
much as possible to make cesarean surgery more family-friendly. Some components of this
approach may include [116]:
Playing background music of the mothers and fathers choice during delivery, and
dimming lights when safely possible
Using clear drapes and positioning the drapes to allow the mother (and father) to watch the
birth
Avoiding maternal sedation
Allowing the baby to deliver by a combination of uterine expulsion and active physician
assistance to mimic expulsion from the vagina
Freeing the mothers dominant hand/arm and chest/breasts from lines and monitors, when
possible, so she can hold and nurse her infant
Promoting skin-to-skin contact and nursing immediately after birth
GUIDELINES FROM NATIONAL ORGANIZATIONS Selected publications on cesarean
delivery from national organizations are listed below:
American College of Obstetricians and Gynecologists (ACOG) [117]
National Institute for Health (NIH) and Clinical Excellence [118]
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials,
"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain
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th
grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at
the 10
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to 12
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grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
Basics topics (see "Patient information: C-section (cesarean delivery) (The Basics)")
Beyond the Basics topics (see "Patient information: C-section (cesarean delivery) (Beyond
the Basics)")
SUMMARY AND RECOMMENDATIONS
Cesarean delivery is performed when the clinician and patient feel that abdominal delivery
is likely to provide a better maternal or fetal outcome than vaginal delivery. A wide variety of
conditions fulfill these criteria. (See 'Indications and contraindications' above.)
Before scheduled cesarean delivery, assurance of fetal pulmonary maturity should be
based on a gestational age of at least 39 weeks or invasive testing. (See 'Assessment of
fetal pulmonary maturity' above.)
For all women undergoing cesarean delivery, we recommend preoperative antibiotic
prophylaxis rather than prophylaxis after cord clamping (Grade 1A). Antibiotics are given 0
to 60 minutes before making the incision. We use a single intravenous dose of a narrow
spectrum antibiotic, such as cefazolin (2 grams for patients <120 kg and 3 grams for
patients 120 kg) (table 2). Multiple doses and broad spectrum antibiotics are more costly,
without clearly improving outcome. (See 'Antibiotic prophylaxis' above.)

We use clindamycin and gentamicin for women with a serious penicillin allergy (table 2).
(See 'Penicillin allergy' above.)
For all women undergoing cesarean delivery, we suggest mechanical thromboprophylaxis
(Grade 2C). For women undergoing cesarean delivery at high risk of venous
thromboembolism, we suggest mechanical thromboprophylaxis plus pharmacological
thromboprophylaxis (Grade 2C). Pharmacologic prophylaxis is begun 6 to 12 hours
postoperatively, after concerns for hemorrhage have decreased. Mechanical and
pharmacological prophylaxis are continued until the woman is fully ambulating.
(See'Thromboembolism prophylaxis' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Betrn AP, Merialdi M, Lauer JA, et al. Rates of caesarean section: analysis of global, regional
and national estimates. Paediatr Perinat Epidemiol 2007; 21:98.
2. Lumbiganon P, Laopaiboon M, Glmezoglu AM, et al. Method of delivery and pregnancy
outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet
2010; 375:490.
3. Betrn AP, Gulmezoglu AM, Robson M, et al. WHO global survey on maternal and perinatal
health in Latin America: classifying caesarean sections. Reprod Health 2009; 6:18.
4. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final Data for 2011. Natl Vital Stat Rep 2013;
62:1. http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf#table21 (Accessed on August 19,
2013).
5. Gibbons L, Belizan JM, Lauer JA, et al. Inequities in the use of cesarean section deliveries in the
world. Am J Obstet Gynecol 2012; 206:331.e1.
6. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing
countries: a retrospective analysis. Lancet 2006; 368:1516.
7. Tang S, Li X, Wu Z. Rising cesarean delivery rate in primiparous women in urban China:
evidence from three nationwide household health surveys. Am J Obstet Gynecol 2006; 195:1527.
8. Lei H, Wen SW, Walker M. Determinants of caesarean delivery among women hospitalized for
childbirth in a remote population in China. J Obstet Gynaecol Can 2003; 25:937.
9. Zhang J, Liu Y, Meikle S, et al. Cesarean delivery on maternal request in southeast China. Obstet
Gynecol 2008; 111:1077.
10. Kambo I, Bedi N, Dhillon BS, Saxena NC. A critical appraisal of cesarean section rates at
teaching hospitals in India. Int J Gynaecol Obstet 2002; 79:151.
11. Boyle A, Reddy UM, Landy HJ, et al. Primary cesarean delivery in the United States. Obstet
Gynecol 2013; 122:33.
12. Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in
singletons. Cochrane Database Syst Rev 2013; 9:CD000078.
13. Luthy DA, Wardinsky T, Shurtleff DB, et al. Cesarean section before the onset of labor and
subsequent motor function in infants with meningomyelocele diagnosed antenatally. N Engl J
Med 1991; 324:662.
14. How HY, Harris BJ, Pietrantoni M, et al. Is vaginal delivery preferable to elective cesarean
delivery in fetuses with a known ventral wall defect? Am J Obstet Gynecol 2000; 182:1527.
15. Walker SP, McCarthy EA, Ugoni A, et al. Cesarean delivery or vaginal birth: a survey of patient
and clinician thresholds. Obstet Gynecol 2007; 109:67.
16. Lyerly AD, Mitchell LM, Armstrong EM, et al. Risks, values, and decision making surrounding
pregnancy. Obstet Gynecol 2007; 109:979.
17. American College of Obstetricians and Gynecologists. Patient Safety Checklist no. 4:
preoperative planned cesarean delivery. Obstet Gynecol 2011; 118:1471.
18. American College of Obstetricians and Gynecologists. Patient Safety Checklist no. 3: scheduling
planned cesarean delivery. Obstet Gynecol 2011; 118:1469.
19. American College of Obstetricians and Gynecologists and American Academy of Pediatrics.
Guidelines For Perinatal Care, 7th ed, 2012.
20. Stutchfield P, Whitaker R, Russell I, Antenatal Steroids for Term Elective Caesarean Section
(ASTECS) Research Team. Antenatal betamethasone and incidence of neonatal respiratory
distress after elective caesarean section: pragmatic randomised trial. BMJ 2005; 331:662.
21. Zanardo V, Padovani E, Pittini C, et al. The influence of timing of elective cesarean section on
risk of neonatal pneumothorax. J Pediatr 2007; 150:252.
22. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants
delivered by elective caesarean section: cohort study. BMJ 2008; 336:85.
23. Zanardo V, Simbi AK, Franzoi M, et al. Neonatal respiratory morbidity risk and mode of delivery at
term: influence of timing of elective caesarean delivery. Acta Paediatr 2004; 93:643.
24. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term:
influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101.
25. Wax JR, Herson V, Carignan E, et al. Contribution of elective delivery to severe respiratory
distress at term. Am J Perinatol 2002; 19:81.
26. Yee W, Amin H, Wood S. Elective cesarean delivery, neonatal intensive care unit admission, and
neonatal respiratory distress. Obstet Gynecol 2008; 111:823.
27. Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with elective
term delivery. Am J Obstet Gynecol 2009; 200:156.e1.
28. Wilmink FA, Hukkelhoven CW, Lunshof S, et al. Neonatal outcome following elective cesarean
section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. Am J
Obstet Gynecol 2010; 202:250.e1.
29. Nir V, Nadir E, Feldman M. Late better than early elective term Cesarean section. Acta Paediatr
2012; 101:1054.
30. Glavind J, Kindberg SF, Uldbjerg N, et al. Elective caesarean section at 38 weeks versus 39
weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2013; 120:1123.
31. Cousins LM, Teplick FB, Poeltler DM. Pre-cesarean blood bank orders: a safe and less
expensive approach. Obstet Gynecol 1996; 87:912.
32. Ransom SB, Fundaro G, Dombrowski MP. Cost-effectiveness of routine blood type and screen
testing for cesarean section. J Reprod Med 1999; 44:592.
33. Rouse DJ, MacPherson C, Landon M, et al. Blood transfusion and cesarean delivery. Obstet
Gynecol 2006; 108:891.
34. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines
for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task
Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
35. Chua SC, Joung SJ, Aziz R. Incidence and risk factors predicting blood transfusion in caesarean
section. Aust N Z J Obstet Gynaecol 2009; 49:490.
36. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al.
Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection
Prevention Project. Clin Infect Dis 2004; 38:1706.
37. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after
cesarean section. Cochrane Database Syst Rev 2010; :CD007482.
38. Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section:
a systematic review and meta-analysis. BJOG 2013; 120:661.
39. Dinsmoor MJ, Gilbert S, Landon MB, et al. Perioperative antibiotic prophylaxis for nonlaboring
cesarean delivery. Obstet Gynecol 2009; 114:752.
40. Ledger WJ, Blaser MJ. Are we using too many antibiotics during pregnancy? BJOG 2013;
120:1450.
41. Alfirevic Z, Gyte GM, Dou L. Different classes of antibiotics given to women routinely for
preventing infection at caesarean section. Cochrane Database Syst Rev 2010; :CD008726.
42. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial
prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
43. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73.
44. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of
prophylactic cefazolin during cesarean delivery. Obstet Gynecol 2011; 117:877.
45. Tita AT, Rouse DJ, Blackwell S, et al. Emerging concepts in antibiotic prophylaxis for cesarean
delivery: a systematic review. Obstet Gynecol 2009; 113:675.
46. Andrews WW, Hauth JC, Cliver SP, et al. Randomized clinical trial of extended spectrum
antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-cesarean delivery
endometritis. Obstet Gynecol 2003; 101:1183.
47. Tita AT, Hauth JC, Grimes A, et al. Decreasing incidence of postcesarean endometritis with
extended-spectrum antibiotic prophylaxis. Obstet Gynecol 2008; 111:51.
48. Tita AT, Owen J, Stamm AM, et al. Impact of extended-spectrum antibiotic prophylaxis on
incidence of postcesarean surgical wound infection. Am J Obstet Gynecol 2008; 199:303.e1.
49. Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane
Database Syst Rev 2013; 12:CD001058.
50. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 120: Use of
prophylactic antibiotics in labor and delivery. Obstet Gynecol 2011; 117:1472.
51. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-
blind studyof single high dose versus multiple standard dose gentamicin both in combination
withmetronidazole for colorectal surgicalprophylaxis. J Hosp Infect 2000; 46:135.
52. Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for cesarean section. Cochrane
Database Syst Rev 2000; :CD001136.
53. Cunningham FG, Leveno KJ, DePalma RT, et al. Perioperative antimicrobials for cesarean
delivery: before or after cord clamping? Obstet Gynecol 1983; 62:151.
54. Gordon HR, Phelps D, Blanchard K. Prophylactic cesarean section antibiotics: maternal and
neonatal morbidity before or after cord clamping. Obstet Gynecol 1979; 53:151.
55. Lindqvist P, Dahlbck B, Marl K. Thrombotic risk during pregnancy: a population study. Obstet
Gynecol 1999; 94:595.
56. Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet 1999; 353:1258.
57. Bain E, Wilson A, Tooher R, et al. Prophylaxis for venous thromboembolic disease in pregnancy
and the early postnatal period. Cochrane Database Syst Rev 2014; 2:CD001689.
58. James A, Committee on Practice BulletinsObstetrics. Practice bulletin no. 123:
thromboembolism in pregnancy. Obstet Gynecol 2011; 118:718.
59. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and
relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199:36.e1.
60. Clark SL, Christmas JT, Frye DR, et al. Maternal mortality in the United States: predictability and
the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related
intracranial hemorrhage. Am J Obstet Gynecol 2014; 211:32.e1.
61. Committee on Practice Bulletins--Gynecology, American College of Obstetricians and
Gynecologists. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and
pulmonary embolism. Obstet Gynecol 2007; 110:429.
62. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and
pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S.
63. SMFM, Publication Committe, with Varner MW. Thromboprophylaxis for cesarean delivery.
Contemp Ob Gyn 2011; 6:30.
64. Dargaud Y, Rugeri L, Vergnes MC, et al. A risk score for the management of pregnant women
with increased risk of venous thromboembolism: a multicentre prospective study. Br J Haematol
2009; 145:825.
65. Danilenko-Dixon DR, Heit JA, Silverstein MD, et al. Risk factors for deep vein thrombosis and
pulmonary embolism during pregnancy or post partum: a population-based, case-control study.
Am J Obstet Gynecol 2001; 184:104.
66. Ettema HB, Kollen BJ, Verheyen CC, Bller HR. Prevention of venous thromboembolism in
patients with immobilization of the lower extremities: a meta-analysis of randomized controlled
trials. J Thromb Haemost 2008; 6:1093.
67. Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous
thrombosis: a hospital-based case-control study. J Thromb Haemost 2008; 6:905.
68. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy
and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006;
194:1311.
69. Macklon NS, Greer IA. Venous thromboembolic disease in obstetrics and gynaecology: the
Scottish experience. Scott Med J 1996; 41:83.
70. Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in
pregnancy and the puerperium: incidence and additional risk factors from a London perinatal
database. BJOG 2001; 108:56.
71. Blondon M, Perrier A, Nendaz M, et al. Thromboprophylaxis with low-molecular-weight heparin
after cesarean delivery. Thromb Haemost 2010; 103:129.
72. Kobayashi T, Nakabayashi M, Ishikawa M, et al. Pulmonary thromboembolism in obstetrics and
gynecology increased by 6.5-fold over the past decade in Japan. Circ J 2008; 72:753.
73. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 37a: Reducing the
risk of thrombosis and embolism during pregnancy and the puerperium. RCOG, London.
November 2009; 1-35.
74. Kent N, Leduc L, Crane J, et al. PREVENTION AND TREATMENT OF VENOUS
THROMBOEMBOLISM (VTE) IN OBSTETRICS. J SOGC 2000; 22:736.
75. Committee on Obstetric Practice. ACOG Committee Opinion No. 382: Fetal Monitoring Prior to
Scheduled Cesarean Delivery. Obstet Gynecol 2007; 110:961.
76. Abdel-Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling bladder catheterisation as part
of intraoperative and postoperative care for caesarean section. Cochrane Database Syst Rev
2014; 4:CD010322.
77. Li L, Wen J, Wang L, et al. Is routine indwelling catheterisation of the bladder for caesarean
section necessary? A systematic review. BJOG 2011; 118:400.
78. Senanayake H. Elective cesarean section without urethral catheterization. J Obstet Gynaecol Res
2005; 31:32.
79. Ghoreishi J. Indwelling urinary catheters in cesarean delivery. Int J Gynaecol Obstet 2003;
83:267.
80. Barnes JS. Is it better to avoid urethral catheterization at hysterectomy and caesarean section?
Aust N Z J Obstet Gynaecol 1998; 38:315.
81. Nasr AM, ElBigawy AF, Abdelamid AE, et al. Evaluation of the use vs nonuse of urinary
catheterization during cesarean delivery: a prospective, multicenter, randomized controlled trial. J
Perinatol 2009; 29:416.
82. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev 2006; :CD004122.
83. Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973;
107:206.
84. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for
Surgical-Site Antisepsis. N Engl J Med 2010; 362:18.
85. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939
wounds. Surg Clin North Am 1980; 60:27.
86. Hayek LJ, Emerson JM, Gardner AM. A placebo-controlled trial of the effect of two preoperative
baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp
Infect 1987; 10:165.
87. Rotter ML, Hirschl AM, Koller W. Effect of chlorhexidine-containing detergent, non-medicated
soap or isopropanol and the influence of neutralizer on bacterial pathogenicity. J Hosp Infect
1988; 11:220.
88. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical
site infection. Cochrane Database Syst Rev 2006; :CD004985.
89. Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for preventing infection following caesarean
section. Cochrane Database Syst Rev 2012; 9:CD007462.
90. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean
section for preventing postoperative infections. Cochrane Database Syst Rev 2013; 1:CD007892.
91. American College of Obstetricians and Gynecologists Women's Health Care Physicians,
Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical
preparation of the vagina. Obstet Gynecol 2013; 122:718.
92. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of
postcesarean endometritis: a randomized controlled trial. Obstet Gynecol 2001; 98:745.
93. Cordtz T, Schouenborg L, Laursen K, et al. The effect of incisional plastic drapes and
redisinfection of operation site on wound infection following caesarean section. J Hosp Infect
1989; 13:267.
94. Ward HR, Jennings OG, Potgieter P, Lombard CJ. Do plastic adhesive drapes prevent post
caesarean wound infection? J Hosp Infect 2001; 47:230.
95. Lee SW, Khaw KS, Ngan Kee WD, et al. Haemodynamic effects from aortocaval compression at
different angles of lateral tilt in non-labouring term pregnant women. Br J Anaesth 2012; 109:950.
96. Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree
and direction of lateral tilt on maternal cardiac output. Anesth Analg 2003; 97:256.
97. Kundra P, Velraj J, Amirthalingam U, et al. Effect of positioning from supine and left lateral
positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients.
Anaesthesia 2012; 67:889.
98. Kinsella SM, Harvey NL. A comparison of the pelvic angle applied using lateral table tilt or a
pelvic wedge at elective caesarean section. Anaesthesia 2012; 67:1327.
99. Calvache JA, Muoz MF, Baron FJ. Hemodynamic effects of a right lumbar-pelvic wedge during
spinal anesthesia for cesarean section. Int J Obstet Anesth 2011; 20:307.
100. Cluver C, Novikova N, Hofmeyr GJ, Hall DR. Maternal position during caesarean section
for preventing maternal and neonatal complications. Cochrane Database Syst Rev 2013;
3:CD007623.
101. Lagrew DC, Bush MC, McKeown AM, Lagrew NG. Emergent (crash) cesarean delivery:
indications and outcomes. Am J Obstet Gynecol 2006; 194:1638.
102. MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery
intervals for "emergency" caesarean section. BMJ 2001; 322:1334.
103. American College of Obstetricians and Gynecologists. Optimal goals for anesthesia care
in obstetrics. ACOG Committee Opinion #256. American College of Obstetricians and
Gynecologists, Washington, DC 2001.
104. James D. Caesarean section for fetal distress. BMJ 2001; 322:1316.
105. Helmy WH, Jolaoso AS, Ifaturoti OO, et al. The decision-to-delivery interval for
emergency caesarean section: is 30 minutes a realistic target? BJOG 2002; 109:505.
106. Tuffnell DJ, Wilkinson K, Beresford N. Interval between decision and delivery by
caesarean section-are current standards achievable? Observational case series. BMJ 2001;
322:1330.
107. Chauhan SP, Roach H, Naef RW 2nd, et al. Cesarean section for suspected fetal
distress. Does the decision-incision time make a difference? J Reprod Med 1997; 42:347.
108. MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by
caesarean section? Evidence from 415 deliveries. BJOG 2002; 109:498.
109. Thomas J, Paranjothy S, James D. National cross sectional survey to determine whether
the decision to delivery interval is critical in emergency caesarean section. BMJ 2004; 328:665.
110. Holcroft CJ, Graham EM, Aina-Mumuney A, et al. Cord gas analysis, decision-to-delivery
interval, and the 30-minute rule for emergency cesareans. J Perinatol 2005; 25:229.
111. Bloom SL, Leveno KJ, Spong CY, et al. Decision-to-incision times and maternal and
infant outcomes. Obstet Gynecol 2006; 108:6.
112. Tolcher MC, Johnson RL, El-Nashar SA, West CP. Decision-to-incision time and
neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol 2014; 123:536.
113. Stallings SP, Edwards RK, Johnson JW. Correlation of head-to-body delivery intervals in
shoulder dystocia and umbilical artery acidosis. Am J Obstet Gynecol 2001; 185:268.
114. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol
1986; 68:571.
115. Myers RE. Two patterns of perinatal brain damage and their conditions of occurrence.
Am J Obstet Gynecol 1972; 112:246.
116. Smith J, Plaat F, Fisk NM. The natural caesarean: a woman-centred technique. BJOG
2008; 115:1037.
117. ACOG Task Force on Cesarean Delivery Rates. Evaluation of cesarean delivery,
American College of Obstetricians and Gynecologists, Washington, DC 2000.
118. National Institute for Health and Clinical Excellence (NICE). Caesarean section.
http://guidance.nice.org.uk/cg132 (Accessed on January 23, 2012).