This document provides guidelines for procedural aspects of caesarean sections (CS). It discusses topics such as: timing of planned CS to reduce neonatal risks; classification and timeframes for emergency CS categories; preoperative testing and preparation; regional anesthesia preferences; techniques to reduce infection risks and prevent transmission; surgical techniques for skin incision, uterine closure, and more; and thromboprophylaxis and accommodating women's preferences.

1. CAESAREAN
BIRTH
PROCEDURAL
ASPECTS
NICE
guideline,
March
2021
Prof
Aboubakr
Elnashar
Benha
university
Hospital
ABOUBAKR
ELNASHAR
PROCEDURAL
ASPECTS
OF
CS
▪
Timing
of
planned
CS:
Do
not
routinely
carry
out
planned
CS
before
39
w,
as
this
can
increase
the
risk
of
respiratory
morbidity
in
babies.
▪
Classification
of
urgency
for
CS
•
Category
1.
Immediate
threat
to
the
life
of
the
woman
or
fetus
(for
example,
suspected
uterine
rupture,
major
placental
abruption,
cord
prolapse,
fetal
hypoxia
or
persistent
fetal
bradycardia).
•
Category
2.
Maternal
or
fetal
compromise
which
is
not
immediately
life-threatening.
•
Category
3.
No
maternal
or
f
compromise
but
needs
early
birth.
•
Category
4.
Birth
timed
to
suit
woman
or
healthcare
provider.
ABOUBAKR
ELNASHAR

2. ▪
Decision-to-birth
interval
for
unplanned
and
emergency
CS
▪
Category
1:
when
there
is
immediate
threat
to
the
life
of
the
woman
or
fetus
▪
Category
2:
when
there
is
maternal
or
fetal
compromise
which
is
not
immediately
life-threatening.
▪
Perform
category
1
CS
as
soon
as
possible,
and
in
most
situations
within
30
minutes
of
making
the
decision.
▪
Perform
category
2
CS
as
soon
as
possible,
and
in
most
situations
within
75
minutes
of
making
the
decision.
▪
Take
into
account
the
condition
of
the
woman
and
the
unborn
baby
when
making
decisions
about
rapid
birth.
▪
Rapid
birth
can
be
harmful
in
certain
circumstances.
ABOUBAKR
ELNASHAR
▪
Preoperative
testing
and
preparation
for
caesarean
birth
▪
Carry
out:
▪
CBC
to
identify
anaemia,
▪
antibody
screening,
and
▪
blood
grouping
with
saving
of
serum.
▪
Do
not
routinely
carry
out:
•
cross-matching
of
blood
•
clotting
screen
•
preoperative
US
for
localisation
of
the
placenta.
▪
Carry
out
CS
for
antepartum
hage,
abruption
or
pl
praevia
at
a
maternity
unit
with
on-site
blood
transfusion
services,{at
increased
risk
of
blood
loss
of
more
than
1,000
ml}.
▪
With
regional
anaesthesia
an
indwelling
u
catheter
to
prevent
over-distension
of
the
bladder.
ABOUBAKR
ELNASHAR

3. ▪
Anaesthesia
for
CS
▪
Provide
pregnant
women
having
a
CS
with
information
on
the
different
types
of
post-CS
analgesia,
so
that
they
can
make
an
informed
choice
▪
Offer
women
who
are
having
CS
regional
anaesthesia
in
preference
to
general
anaesthesia,
including
women
who
have
a
diagnosis
of
placenta
praevia
▪
Carry
out
induction
of
anaesthesia,
including
regional
anaesthesia,
for
CS
in
theatre.
▪
Apply
a
left
lateral
tilt
of
up
to
15
degrees
or
appropriate
uterine
displacement
once
the
woman
is
in
a
supine
position
on
the
operating
table
to
reduce
maternal
hypotension.
ABOUBAKR
ELNASHAR
▪
Offer
women
who
are
having
CS
under
spinal
anaesthesia
a
prophylactic
IV
infusion
of
phenylephrine,
started
immediately
after
the
spinal
injection.
▪
Adjust
the
rate
of
infusion
to
keep
maternal
BP
at
90%
or
more
of
baseline
value
and
avoid
decreases
to
less
than
80%
of
baseline.
▪
When
using
phenylephrine
infusion,
give
IV
ephedrine
boluses
to
manage
hypotension
during
CS,
for
example
if
the
HR
is
low
and
BP
is
less
than
90%
of
baseline.
▪
Use
IV
crystalloid
co-loading
in
addition
to
vasopressors
to
reduce
the
risk
of
hypotension
occurring
during
CS.
ABOUBAKR
ELNASHAR

4. ▪
Ensure
each
maternity
unit
has
a
set
of
procedures
for
failed
intubation
during
obstetric
anaesthesia
▪
Offer
women
antacids
and
drugs
(such
as
H2-receptor
antagonists
or
proton
pump
inhibitors)
to
reduce
gastric
volumes
and
acidity
before
CS.
▪
Offer
women
having
a
caesarean
birth
anti-emetics
(either
pharmacological
or
acupressure)
to
reduce
nausea
and
vomiting
during
CS
▪
Include
pre-oxygenation,
cricoid
pressure
and
rapid
sequence
induction
in
general
anaesthesia
for
CS
to
reduce
the
risk
of
aspiration.
ABOUBAKR
ELNASHAR
▪
Prevention
and
management
of
hypothermia
and
shivering
▪
Warm
IV
fluids
(500
ml
or
more)
and
blood
products
used
during
CS
to
37
degrees
Celsius
using
a
fluid
warming
device.
▪
Warm
all
irrigation
fluids
used
during
CS
to
38
to
40
degrees
Celsius
in
a
thermostatically
controlled
cabinet.
▪
Consider
forced
air
warming
for
women
who
shiver,
feel
cold,
or
have
a
temperature
of
less
than
36
degrees
Celsius
during
CS.
ABOUBAKR
ELNASHAR

5. ▪
Surgical
techniques
for
CS
▪
Methods
to
reduce
infectious
morbidity
▪
Use
alcohol-based
chlorhexidine
skin
preparation
before
CS
to
reduce
the
risk
of
wound
infections.
▪
If
alcohol-based
chlorhexidine
skin
preparation
is
not
available,
alcohol-based
iodine
skin
preparation
can
be
used.
▪
Use
aqueous
iodine
vaginal
preparation
before
CS
in
women
with
ruptured
membranes
to
reduce
the
risk
of
endometritis.
▪
If
aqueous
iodine
vaginal
preparation
is
not
available
or
is
contraindicated,
aqueous
chlorhexidine
vaginal
preparation
can
be
used.
ABOUBAKR
ELNASHAR
▪
Methods
to
prevent
HIV
transmission
in
theatre
▪
Wear
double
gloves
when
performing
or
assisting
a
caesarean
birth
for
women
who
have
tested
positive
for
HIV,
to
reduce
the
risk
of
HIV
infection
of
staff.
▪
Follow
general
recommendations
for
safe
surgical
practice
during
caesarean
birth
to
reduce
the
risk
of
HIV
infection
of
staff.
ABOUBAKR
ELNASHAR

6. ▪
Abdominal
wall
incision
▪
Transverse
abdominal
incision:
▪
{make
postoperative
pain
less
likely
&
an
improved
cosmetic
effect
compared
with
a
midline
incision}.
▪
Straight
skin
incision,
3
cm
above
the
symphysis
pubis;
subsequent
tissue
layers
are
opened
bluntly
and,
if
necessary,
extended
with
scissors
and
not
a
knife).
▪
This
allows
for
shorter
operating
times
and
reduces
postoperative
febrile
morbidity.
ABOUBAKR
ELNASHAR
▪
Instruments
for
skin
incision
Do
not
use
separate
surgical
knives
to
incise
the
skin
and
the
deeper
tissues,
as
it
does
not
decrease
wound
infection.
▪
Extension
of
the
uterine
incision
When
there
is
a
well
formed
LUS,
use
blunt
rather
than
sharp
extension
of
the
uterine
incision
to
reduce
blood
loss,
incidences
of
postpartum
hge
and
the
need
for
transfusion
▪
Fetal
laceration
Inform
women
that
the
risk
of
fetal
lacerations
is
about
2%.
▪
Use
of
forceps
Only
use
forceps
if
there
is
difficulty
delivering
the
baby's
head.
The
effect
on
neonatal
morbidity
of
the
routine
use
of
forceps
remains
uncertain.
ABOUBAKR
ELNASHAR

7. ▪
Use
of
uterotonics
Use
oxytocin
5
IU
by
slow
IV
injection
to
encourage
contraction
of
the
uterus
and
decrease
blood
loss.
▪
Method
of
placental
removal
Remove
the
placenta
using
controlled
cord
traction
and
not
manual
removal
to
reduce
the
risk
of
endometritis.
▪
Exteriorisation
of
the
uterus
▪
Perform
intraperitoneal
repair
of
the
uterus
for
CS
▪
Routine
exteriorisation
of
the
uterus
is
not
recommended
because
it
is
associated
with
more
pain
and
does
not
improve
operative
outcomes
such
as
hge
and
infection.
ABOUBAKR
ELNASHAR
▪
Closure
of
the
uterus
▪
Use
single
layer
or
double
layer
uterine
closure,
depending
on
the
clinical
circumstances.
▪
Single
layer
closure
does
not
increase
the
risk
of
postoperative
bleeding
or
uterine
rupture
in
a
subsequent
pregnancy.
▪
Closure
of
the
peritoneum
Do
not
suture
the
visceral
or
the
parietal
peritoneum
to
reduce
operating
time
and
the
need
for
postoperative
analgesia,
and
improve
maternal
satisfaction.
▪
Closure
of
the
abdominal
wall
If
a
midline
abdominal
incision
is
used,
use
mass
closure
with
slowly
absorbable
continuous
sutures
as
this
results
in
fewer
incisional
hernias
and
less
dehiscence
than
layered
closure.
ABOUBAKR
ELNASHAR

8. ▪
Closure
of
SC
tissue
Do
not
routinely
close
SC
tissue
space
unless
the
woman
has
more
than
2
cm
SC
fat,
as
it
does
not
reduce
the
incidence
of
wound
infection.
▪
Use
of
superficial
wound
drains
Do
not
routinely
use
superficial
wound
drains
as
they
do
not
decrease
the
incidence
of
wound
infection
or
wound
haematoma.
▪
Closure
of
the
skin
Consider
using
sutures
rather
than
staples
to
reduce
the
risk
of
superficial
wound
dehiscence.
▪
Umbilical
artery
pH
measurement
Perform
paired
umbilical
artery
and
vein
measurements
of
cord
blood
gases
after
CS
for
suspected
fetal
compromise,
to
allow
for
assessment
of
fetal
wellbeing
and
guide
ongoing
care
of
the
baby.
ABOUBAKR
ELNASHAR
▪
Timing
of
antibiotic
administration
Offer
women
prophylactic
antibiotics
before
skin
incision,
choosing
antibiotics
that
are
effective
against
endometritis,
UTI
and
wound
infections.
▪
Inform
women
that:
endometritis,
UTI
and
wound
infections
occur
in
about
8%
of
women
who
have
had
CS
using
prophylactic
antibiotics
before
skin
incision
reduces
the
risk
of
maternal
infection
more
than
prophylactic
antibiotics
given
after
skin
incision,
and
that
there
is
no
known
effect
on
the
baby
▪
Do
not
use
co-amoxiclav
when
giving
prophylactic
antibiotics
before
skin
incision
ABOUBAKR
ELNASHAR

9. ▪
Thromboprophylaxis
▪
Offer
thromboprophylaxis
▪
Take
into
account
the
risk
of
thromboembolic
disease
when
choosing
the
method
of
prophylaxis
▪
graduated
stockings,
▪
hydration,
▪
early
mobilisation,
▪
low
molecular
weight
heparin
▪
Women's
preferences
during
caesarean
birth
Accommodate
a
woman's
preferences
whenever
possible,
such
as,
music
playing
in
theatre,
lowering
the
screen
to
see
the
baby
born,
or
silence
so
that
the
mother's
voice
is
the
first
the
baby
hears.
ABOUBAKR
ELNASHAR