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TABLE 1
Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society
recommendations
Evidence Recommendation
Item Recommendation level grade
Intraoperative pathway focused: 1. Intravenous antibiotics should be administered routinely High Strong
preoperative antimicrobial prophylaxis and within 60 min before the cesarean delivery skin incision.
skin preparation (focused elements) In all women, a first-generation cephalosporin is
recommended; in women in labor or with ruptured
membranes, the addition of azithromycin confers
additional reduction in postoperative infections.
2. Chlorhexidine-alcohol is preferred to aqueous Low Strong
povidone-iodine solution for abdominal skin
cleansing before cesarean delivery.
3. Vaginal preparation with povidine-iodine solution should Moderate Weak
be considered for the reduction of postcesarean infections.
Intraoperative pathway focused
Pre- and intraoperative anesthetic 1. Regional anesthesia is the preferred method of Low Strong
management (focused element) anesthesia for cesarean delivery as part of an
enhanced recovery protocol.
Prevention of intraoperative hypothermia 1. Appropriate patient monitoring is needed to apply Low Strong
(focused element) warming devices and avoid hypothermia.
2. Forced air warming, intravenous fluid warming, High Strong
and increasing operating room temperature are all
recommended to prevent hypothermia during
cesarean delivery.
Cesarean delivery surgical techniques/ 1. Blunt expansion of a transverse uterine hysterotomy Moderate Weak
considerations (focused element) at time of cesarean delivery is recommended to reduce
surgical blood loss.
2. Closure of the hysterotomy in 2 layers may be Low Weak
associated with a lower rate of uterine rupture.
3. The peritoneum does not need to be closed because Low Weak
closure is not associated with improved outcomes and
increases operative times.
4. In women with 2 cm of subcutaneous tissue, Moderate Weak
reapproximation of that tissue layer should be performed.
5. The skin closure should be closed with subcuticular Moderate Weak
suture in most cases, because of evidence of reduced
wound separation in those women whose staples were
removed 4 days postoperatively.
Perioperative fluid management (focused 1. Perioperative and intraoperative euvolemia are Low- Strong
element) important factors in patient perioperative care and moderate
appear to lead to improved maternal and neonatal
outcomes after cesarean delivery.
Caughey. Guidelines for intraoperative care in cesarean delivery. Am J Obstet Gynecol 2018. (continued)
an increased risk of postoperative infec- the primary issues when considering similar benefits have been seen with
tion and have demonstrated benefit prophylactic antibiotics, wound prepa- other antibiotic regimens.6 Historically,
from prophylactic antibiotics and other ration, and vaginal preparation. because of concerns of fetal exposure,
interventions. Although the class I in- For cesarean delivery performed these antibiotics were often given after
cisions will be predominantly at-risk before rupture of the membranes, the cord clamping. However, because of the
from abdominal skin flora, the class II standard of care has been to use a rela- benefit of a decrease in subsequent
or class III incisions both carry the risk of tively narrow-spectrum first-generation wound infections reported in several
skin flora plus the risk of exposure from cephalosporin directed against skin flora studies, it is now recommended to give
vaginal flora. These microbial risks are for infectious prophylaxis, although the antibiotics 30e60 minutes before the
TABLE 1
Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society
recommendations (continued)
Evidence Recommendation
Item Recommendation level grade
Neonate pathway focused: Immediate care 1. Delayed cord clamping for at least 1 minute at a Moderate Strong
of the newborn infant at delivery (focused term delivery is recommended.
element)
2. Delayed cord clamping for at least 30 seconds at a Low- Strong
preterm delivery is recommended. moderate
3. Body temperature should be measured and Low- Strong
maintained between 36.5 C and 37.5 C after birth moderate
through admission and stabilization.
4. Routine suctioning of the airway or gastric aspiration Low Strong
should be avoided and used only for symptoms of an
obstructive airway (by secretions or meconium).
5. Routine neonatal supplementation with room air is Low- Strong
recommended because the use of inspired air with oxygen moderate
may be associated with harm.
6. In all settings that perform cesarean delivery, a capacity High Strong
for immediate neonatal resuscitation is mandatory.
Caughey. Guidelines for intraoperative care in cesarean delivery. Am J Obstet Gynecol 2018.
cesarean delivery when possible.7,8 The However, in 2 recent prospective, ran- there is a wider body of literature in other
most recent Cochrane review reported a domized trials, there were no differences surgeries, the evidence is more scant in
significant reduction in composite in infectious morbidity between 2-g and the setting of cesarean deliveries19: the
maternal infectious morbidity for 3-g dosing of cephazolin.15,16 Thus, 2014 Cochrane review did not demon-
women who received preoperative pro- further evidence must be collected strate a difference.12 However, there have
phylactic antibiotics as compared with before increased dosing of prophylactic been 2 large studies since that systematic
women who received prophylactic anti- antibiotics in obese women is routinely review. One large study demonstrated a
biotics at the time of cord clamping (risk recommended. lower rate of wound infections with the
ratio, 0.57; 95% confidence interval, Another recent approach to antibiotic chlorhexidine-alcohol scrub.20 However,
0.45e0.72).9 There is increasing evi- prophylaxis in obese women has been another recent large, randomized trial
dence that broadening the preincision postsurgical prophylaxis. In a recent demonstrated no difference.21 Thus,
antibiotic spectrum might further prospective, randomized trial, the risk of although the chlorhexidine-alcohol
reduce the risk of wound infections.10 In surgical site infection was reduced from usually is recommended, it is based not
a recent, multicenter trial, the addition 15.4e6.4% (P¼.01) from the use of only on the studies in cesarean deliveries
of azithromycin to the routine cephalo- cephalosporin and metronidazole versus but also on the wider body of evidence in
sporins further reduced infectious placebo after cesarean delivery.17 How- other surgeries.22
complications from 12.0% to 6.1% ever, this prophylaxis regimen has not
(P<.001) and wound infections from been compared with a preincision pro- Vaginal preparation
6.6e2.4%.11 Additionally, there have tocol that incorporates azithromycin and There is an increasing body of evidence
been studies of the use of antibiotic- requires further study. to suggest that an antimicrobial vaginal
infused drapes without adequate evi- preparation with a povidone-iodine
dence to support routine use.12 Wound preparation solution before cesarean delivery in
There are special concerns for obese Even before the hospital admission for a women in labor or with rupture of
women because of their increased risk of scheduled cesarean delivery, it is recom- membranes reduces the risk of infectious
wound complications and the potential mended that women shower with an complications. In the most recent
of higher blood volume for the antibiotic antimicrobial soap if possible.18 The Cochrane review, the risk of endome-
distribution. In several recent studies, it Centers for Disease Control recommen- tritis was reduced from 8.3e4.3%
has been suggested that the tissue con- dations encourage the use of the (relative risk, 0. 45; 95% confidence
centrations of first-generation cephalo- chlorhexidine-alcohol scrub over the interval, 0.25e0.81).23 In stratified ana-
sporins may not be adequate from povidone-iodine solution to prepare lyses, this was true for women both
the standard 1- or 2-g dosing.13,14 the abdomen before surgery. Although in labor and with ruptured membranes.
TABLE 2
Grading of Recommendations, Assessment, Development and Evaluation system for rating quality of evidence
and strength of recommendations
Grading of Recommendations, Assessment,
Development and Evaluation Definition
5
Rating quality of evidence : evidence level
High quality Further research is unlikely to change confidence in estimate of effect.
Moderate quality Further research is likely to have important impact on confidence in estimate of effect and may
change the estimate.
Low quality Further research is very likely to have important impact on confidence in estimate of effect and
likely to change the estimate.
Very low quality Any estimate of effect is very uncertain.
5
Rating strength of recommendations :
recommendation strength
Strong When desirable effects of intervention clearly outweigh, or are outweighed by, the undesirable
effects.
Weak When trade-offs are less certain, either because of low-quality evidence or because evidence
suggests desirable and undesirable effects are closely balanced.
Caughey. Guidelines for intraoperative care in cesarean delivery. Am J Obstet Gynecol 2018.
Summary and recommendation. nausea and vomiting, number of days The use of intrathecal morphine results
spent in hospital, and adverse events.24 in improved postoperative analgesia,34,35
1. Intravenous antibiotics should be Obstetric anesthesia regional techniques although the risk of side-effects (nausea,
administered routinely within 60 are thought to be safer than general vomiting, and pruritis) increases with
minutes before the cesarean delivery anesthesia and their increased adoption is the dosage used and the optimal dose is
skin incision. In all women, a first- thought to be 1 of the reasons that not established. Shorter acting opioids
generation cephalosporin is recom- maternal death rates because of anes- such as fentanyl and sufentanil, when
mended; in women in labor or with thesia have fallen.25 However, a meta- administered intrathecally, improve the
ruptured membranes, the addition analysis of mode of anesthesia for intraoperative but not the postoperative
of azithromycin confers additional cesarean delivery26 reported that, other analgesia.34 In the absence of intrathecal
reduction in postoperative infections than a higher maternal blood loss with morphine, the transversus abdominis
(evidence level: high/recommenda- general anesthesia, there was no evidence plane field block provides superior
tion grade: strong). that regional anesthesia was superior to analgesia when compared with a placebo
2. Chlorhexidine-alcohol is preferred to general anesthesia in terms of major and can reduce the first 24-hour
aqueous povidone-iodine solution maternal or neonatal outcomes. This may maternal morphine consumption in the
for abdominal skin cleansing before be due to the infrequency of death and setting of a multimodal analgesic
cesarean delivery (evidence level: serious morbidity that leads to the inad- regimen.36 A Cochrane review of local
low/recommendation grade: strong). equate power of most studies. Addition- analgesia infiltration and abdominal
3. Vaginal preparation with povidone- ally, because of a greater potential for nerve blocks found that these infiltrative
iodine solution should be consid- postoperative sedation with general techniques improved postoperative
ered for the reduction of infections anesthesia, regional anesthesia may be the analgesia for caesarean delivery.37
after cesarean delivery (evidence preferable choice in this regard.27e29
level: moderate/recommendation Outcomes are similar for spinal and Summary and recommendation. Re-
grade: weak). epidural anesthesia30; the onset time for gional anesthesia is the preferred method
an effective block is shorter and the of anesthesia for caesarean delivery as
Intraoperative cesarean delivery incidence of intraoperative pain is lower part of an enhanced recovery protocol
pathway (focused elements) for spinal than for epidural anesthesia.31 (evidence level: low/recommendation
Pre- and intraoperative anesthetic man- Combined spinal epidural anesthesia grade: strong).
agement (focused element) may allow for a more rapid motor
Regional anesthesia has been found to recovery than spinal anesthesia,32 Prevention of intraoperative hypothermia
have a positive impact for enhanced re- although the presence of an epidural (focused element)
covery outcomes in terms of pain control, catheter provides a capability to extend Perioperative hypothermia can occur in
organ function, mobility, postoperative or prolong an inadequate spinal block.33 50e80% of patients who undergo spinal
anesthesia for cesarean delivery.38,39 Summary and recommendation. incised only at the midline in a transvers
Several randomized control studies fashion. The rectus sheath is separated
showed that perioperative hypothermia 1. Appropriate patient temperature along its fibers with blunt dissection, and
is associated with complications in monitoring is needed to apply the rectus muscles are separated by pull-
nonpregnant patients.40,41 These com- warming devices and avoid hypo- ing. The parietal peritoneum is opened
plications have included surgical site thermia (evidence level: low/recom- digitally at the upper level of the inter-
infection, myocardial ischemia, altered mendation grade: strong). muscular space and stretched in a cranial-
drug metabolism, coagulopathy, pro- 2. Forced air warming, intravenous caudal direction. A small transverse
longed duration of hospitalization, fluid warming, and increasing oper- incision is made into the uterus with a
shivering, reduced skin integrity, and ating room temperature are scalpel, 2 cm above the vesical-uterine
poor patient satisfaction.42e44 Hypo- all recommended to prevent hypo- fold until the membranes bulge, and 2
thermia can also have adverse effects on thermia during cesarean delivery index fingers are inserted to stretch the
neonates, such as temperature, umbilical (evidence level: moderate/recom- opening laterally. A modification to this
pH, Apgar score.45,46 mendation grade: strong). of cranial-caudal expansion has been
Generally, patient core temperature is described and is associated with fewer
monitored poorly during neuraxial Cesarean delivery surgical techniques/ extensions and less blood loss.57,58 Over-
anesthesia.47,48 Skin temperature moni- considerations (focused element) all, the Joel-Cohen approach has been
toring can be used during neuraxial In the last decades, cesarean delivery associated with lower operative times and
anesthesia, but the temperatures are rates have increased in many countries lower blood loss.59
2.0e4.0 C less than the core tempera- and have become the most commonly
ture.49 Axillary temperatures can be performed intraperitoneal surgical pro- Repair of incision
measured if the sensor is placed over the cedure. Despite its worldwide spread, a The uterine incision is repaired
axillary artery with arms adducted to the consensus on the most appropriate ce- commonly in 1 or 2 layers with a
side.50 Thus, it is important to consider sarean delivery technique to use has not continuous unlocked suture.60e62
how to best monitor a patient’s temper- yet been reached.54 The operative tech- Generally, a 2-layer closure has been
ature during surgery. nique performed generally is based on used because of nonrandomized trial ev-
A recent systematic review (13 ran- the individual experience and preference idence that suggests a higher rate of
domized controlled studies and 789 pa- of operators, the characteristics of pa- uterine rupture in women who had
tients) examined the efficacy of active tients, and the timing and urgency of the pregnancies after a previous cesarean
warming during cesarean delivery.51 The intervention. However, there are many delivery with hysterotomies closed in a
active warming methods included forced randomized trials that have examined a single layer. However, the most recent
air warming and intravenous fluid variety of the approaches to various Cochrane review did not find a difference
warming. Active warming group (either components of the cesarean delivery; in in outcomes between 1- or 2-layer
forced air warming or intravenous fluid 1 recent study when a range of evidence- closure.58 The use of a delayed absorb-
warming) patients had significantly less based approaches were adopted, cesar- able monofilament (Monocryl; Ethicon
temperature change (P¼.0002), fewer ean delivery wound complications were Inc, Bridgewater, NJ) has been described,
shivering episodes (P¼.0004), higher reduced.55 as has chromic catgut and Vicryl (Ethicon
temperature at end of surgery or on Inc), without strong evidence to support
arrival to the postanesthetic care unit Surgical incision a particular suture. There are studies of
(P<.00001), and higher umbilical artery The traditional approach to the cesarean blunt vs sharp needles that do not
pH (P¼.04). A randomized controlled delivery has been the Pfannenstiel skin demonstrate benefit to patients.63 In such
study showed fluid warming combined incision that is made sharply through the studies, a reduction in glove perforations
with forced air warming to be effective in subcutaneous tissue, sharply through the is seen (relative risk, 0.54; 95% confi-
decreasing the incidence of perioperative fascia, and sharply entering the parietal dence interval, 0.41e0.71), but providers
hypothermia and improving maternal peritoneum. The Kerr hysterotomy is also are less satisfied with blunt needles.64
thermal comfort.52 made sharply in a transverse fashion into Historically, the visceral and parietal
Ambient operating room tempera- the uterus. A bladder flap commonly was peritoneum were closed; however, in sys-
ture can affect maternal and neonatal created to dissect the bladder inferiorly tematic reviews, there is no evidence that
temperature. A randomized controlled away from the hysterotomy, although a outcomes such as intraabdominal adhe-
trial with 799 patients demonstrated recent metaanalysis does not support this sions are different and that the operative
that operating room temperature at being performed routinely.56 times are shorter leaving the peritoneum
23.0 C resulted in significantly lower More recently, the Joel-Cohen incision open.56,65 Similarly, the rectus muscles
maternal hypothermia when compared has been described. The subcutaneous commonly were sutured at the midline,
with the operating room temperature at tissue is left undisturbed apart from the but there is no evidence to support
20.0 C.53 midline, and the abdominal fascia is closure, and there is concern that
intramuscular sutures will tear through.66 Summary and recommendation. during spinal anesthesia for cesarean
The abdominal fascia is usually closed delivery.80,81 Perioperative fluid man-
with a continuous suture, PDS or Vicryl.67 1. Blunt expansion of a transverse agement is always a controversial topic
The subcutaneous tissue, when it is <2 uterine hysterotomy at time of ce- in anesthesia practice. Adequate peri-
cm in thickness is often not reapproxi- sarean delivery is recommended to operative fluid administration can
mated. However, in women whose sub- reduce surgical blood loss (evidence reduce surgical morbidities.82 Although
cutaneous tissue is 2 cm in thickness, level: moderate/recommendation the use of intravenous fluids to preload
reapproximation with catgut or Vicryl grade: weak). the circulation is recommended, a recent
suture has been demonstrated to reduce 2. Closure of the hysterotomy in 2 layers consensus statement and accompanying
wound complications.68 Placement of a may be associated with a lower rate of editorial suggest that intravenous fluids
subcutaneous drain even with wounds >4 uterine rupture (evidence level: low/ alone have limited efficacy and that
cm in thickness has not been demon- recommendation grade: weak). many clinicians now administer pro-
strated to improve outcomes and has been 3. The peritoneum does not need to be phylactic phenylephrine infusions,
associated with worse wound outcomes. closed because closure is not associated which not only prevent hypertension but
The skin can be closed with staples or with improved outcomes and in- also reduce the risk of fetal acidosis.83,84
subcuticular/intracutaneous techniques creases operative times (evidence level: One metaanalysis and systematic review
with Vicryl or Monocryl. The most low / recommendation grade: weak). showed that the use of goal-directed
recent Cochrane metaanalysis found no 4. In women with 2 cm of subcu- fluid therapy in patients who under-
difference between the 2 approaches taneous tissue, reapproximation of went major surgery reduced post-
with regards to wound infections or that tissue layer should be performed operative complications such as wound
complications overall.69 However, there (evidence level: moderate/recom- infection, abdominal complications, and
was a large trial published in 2014 that mendation grade: weak). hypotension.85 Another metaanalysis
demonstrated a significant reduction in 5. The skin closure should be closed and systematic review indicated that
wound complications70; in a subsequent with subcuticular suture in most goal-directed fluid therapy significantly
metaanalysis of skin closure that incor- cases, because of evidence of reduced reduced the incidence of surgical site
porated this trial, subcuticular closure wound separation in those whose infections and length of hospital stay
with suture was supported for the staples were removed 4 days after after abdominal surgery.86 However, the
reduction in wound complications.71 surgery (evidence level: moderate/ number of high-quality research trials
Additionally, women also have recommendation grade: weak). that have evaluated the effects of goal-
improved preference and experience directed fluid therapy during cesarean
scores with suture closure.72 One caveat Perioperative fluid management delivery is too few to provide consistent
is that the only difference is in wound (focused element) evidence of benefit.
separation; in many trials, staples were Perioperative euvolemia is an important More complex areas include patients
removed <4 days after surgery. Similarly, factor to obtain optimal outcomes after with cardiovascular disease, such as se-
in a recent trial of obese women only, cesarean delivery. Intravascular volume vere preeclampsia and preexisting car-
although there were no clinical differ- determines not only blood pressure but diac disease. These patients should have
ences, more women would choose su- also cardiac output and oxygen delivery. multidisciplinary preoperative assess-
ture for a future surgery.73 Maintaining adequate uterine perfusion ment and planning and may require
Once the wound is closed, there is cannot only optimize fetal oxygenation invasive blood pressure monitoring and
increasing evidence that prophylactic and prevent acidosis but also deliver cardiac output measurements to opti-
negative-pressure wound therapy may be nutrients and eliminate waste products mize both fluid management and the use
useful, particularly in obese women. In a from the uterine myometrium.75 Peri- of vasoactive drugs or inotropes. These
recent systematic review, there was evi- operative fluid overload has higher risks patients require vigilance not only before
dence of reduction in wound infections of increased cardiovascular work and delivery of the fetus but also with the
(relative risk, 0.45; 95% confidence inter- pulmonary edema in pregnant cardiovascular changes that may occur
val, 0.31e0.66) and overall wound com- women.76 Maternal intrapartum fluid after the use of uterotonics and uterine
plications (relative risk, 0.68; 95% overload can result in newborn infant contraction after delivery.
confidence interval, 0.49e0.94) in high- weight loss during the first 3 days after
risk women (predominantly obese) who birth.77,78 Summary and recommendation. Pre-
were assigned randomly to receive the The incidence of hypotension, after operative and intraoperative euvolemia
negative-pressure dressing.74 There are spinal anesthesia, is high and can cause are important factors in patient periop-
several ongoing trials at this time; thus, severe effects on the mother and fetus.79 erative care and appear to lead to
although it would be reasonable for a Studies show that a combination of va- improved maternal and neonatal out-
clinician to use this technology, there is a sopressors and adequate fluid therapy comes after cesarean delivery (evidence
need for additional research to fully could be effective in reducing the inci- level: low to moderate/recommendation
address this question. dence and severity of hypotension grade: strong).
Neonate pathway (focused element) neonatal normothermia.99 Immediate lung disease/neurodevelopmental out-
Immediate care of the newborn infant drying and covering of the infant’s head comes). Electrocardiogram use is sup-
(optimized element) reduce heat losses while awaiting cord ported, although the other monitoring
The stress of being born exceeds that of clamping. Use of exothermic heaters or requires further evaluation.107
most other critical life-events, and there open bed incubators, transwarmer mat- Neonatal morbidity in a planned ce-
are significant transitions in physiology tresses, plastic wraps/bags, and caps all sarean delivery setting was compared in 2
to accomplish. To promote a safe and keep preterm infants warmer and cohorts of women, those with no labor
successful transition from fetal to lead to higher temperatures on admis- and those with spontaneous onset of la-
neonatal life, the immediate care of the sion to neonatal units and less bor before the cesarean delivery.108 Data
newborn infant is important. hypothermia.100e103 Body temperature were stratified for early term (37e38
In all settings that perform cesarean should be measured and maintained weeks) and full term (39e40 weeks).
delivery, fitness for service includes a between 36.5 C and 37.5 C after birth Among 103,919 live births, there were
capacity (equipment, staffing, and skills) through admission and stabilization.87 5071 nonlabor and 731 postlabor onset
and preparedness for immediate Besides hypothermia prevention, cesarean deliveries. Similar risks for
neonatal resuscitation if needed.87 Apgar supporting the infant to regain body neonatal admission and respiratory
scores are important health and perfor- control and gently stimulating for first distress were found for the 2 groups, but a
mance indicators and should be assessed breath or cry are recommended. 2- to 3-fold increase for neonatal septi-
and documented at 1, 5, and 10 minutes Approximately 85% of babies who are cemia or antibiotic use at early term was
after delivery. For the vigorous infant, born at term will initiate spontaneous identified. Labor onset at early term had
interventions in the operating room respirations within 10e30 seconds of decreased maternal blood loss of >500
include optimal timing of umbilical cord birth; an additional 10% will respond mL after cesarean delivery but increased
clamping, hypothermia prevention, during drying and stimulation, whereas endometritis and antibiotic use. The
facilitating onset of breathing, and the remaining 5% need some form of conclusion was that labor onset before
maternal-neonatal skin-to-skin contact. assisted ventilation.87 Routine suction- planned cesarean delivery was not asso-
Delay of clamping of the umbilical ing of the airway or gastric aspiration ciated with a decrease in neonatal respi-
cord for at least 1 minute after term should be avoided; secretions should be ratory morbidity but may be associated
delivery decreases anemia in infancy and cleared only if they appear to be with increased risks of neonatal infection.
improves neurodevelopmental out- obstructing the airway. A similar
comes.88e91 In cesarean delivery, the approach is recommended if meconium Summary and recommendations.
newborn infant can be placed on the is present in the amniotic fluid.87,104,105
maternal abdomen or legs or held by Routine neonatal supplementation 1. Delayed cord clamping for at least 1
the surgeon or assistant close to the level (outside resuscitation) of the inspired air minute at a term delivery is recom-
of the placenta until the umbilical cord with oxygen may be associated with mended (evidence level: moderate/
is clamped.92 In preterm infants, harm and is not recommended.106 recommendation grade: strong).
delayed cord clamping for at least 30 The care of the preterm infant (<37 2. Delayed cord clamping for at least
seconds has been reported in systematic weeks gestation) can be optimized, 30 seconds at a preterm delivery is
reviews to contribute to less need for starting in the delivery room. Katheria recommended (evidence level: low-
transfusion, less intraventricular hem- et al107 review the use of checklists, moderate/recommendation grade:
orrhage, and lower risk for necrotizing avoidance of early cord clamping, strong).
enterocolitis than after immediate cord resuscitation during delayed cord 3. Body temperature should be
clamping.93e97 These findings have been clamping, consideration for early measured and maintained at between
challenged by a large and recent ran- administration of caffeine soon after 36.5 C and 37.5 C after birth,
domized controlled trial.98 Because birth, and the use of additional physio- through admission and stabilization
delayed cord clamping is associated with logic monitoring (electrocardiogram, (evidence level: low-moderate/
increased risk for hyperbilirubinemia, carbon dioxide, respiratory function recommendation grade: strong).
care providers should ensure they can (airway pressure/tidal volume) in the 4. Routine suctioning of the airway or
monitor for and treat neonatal delivery area. A delivery room resusci- gastric aspiration should be avoided
jaundice.88e91 Immediate cord clamping tation checklist directs communication and used only for symptoms of an
should be restricted to infants with im- and directed care. The benefits of obstructive airway (by secretions or
mediate need of resuscitation or when delayed cord clamping and, if required, meconium; evidence level: low/
placental circulation is not intact. cord milking for cesarean delivery were recommendation grade: strong).
Hypothermia is associated with supported. The early use of caffeine is 5. Routine neonatal supplementation
increased neonatal morbidity and death discussed; however, larger prospective with room air is recommended
across gestational ages. Standards for trials are required that are related to because the use of inspired air
operating room temperature (21e25 C) intubation, intraventricular hemor- with oxygen is not recommended and
may maintain both maternal and rhage, and long-term outcome (chronic may be associated with harm
TABLE 3
Enhanced Recovery After Surgery for cesarean delivery preoperative modifiable clinical factors
Nonmodifiable clinical factors Modifiable clinical factors
Paternal age
History (obstetrics/medical/surgery/body mass Optimization of selected comorbidities (hypertension/diabetes mellitus/anemia/smoking; small
index) for gestational age/large for gestational
age/stillbirth/preterm birth at <34 weeks gestation)
Family history (genetics/birth defects/ Surgical pathway (preoperative, intraoperative, postoperative)
multifactorial disease)
Gestational weeks 0e20 (chromosomes/birth
defects/miscarriage)
Caughey. Guidelines for intraoperative care in cesarean delivery. Am J Obstet Gynecol 2018.
(evidence level: low-moderate/ 31.9% in 2015 in the United States. In uterine hematoma (4e6%), placenta
recommendation grade: strong). response to this increasing surgical ac- previa (1e2%), red cell transfusions
6. In all settings that perform cesarean tivity, many groups have attempted to (1e4%), hysterectomy (0.5e4%), and
delivery, a capacity for immediate initiate process change, but the ap- placenta accreta (0.25e3%).115 Initia-
neonatal resuscitation is mandatory proaches have varied and clinical care tives to reduce the frequency of cesarean
(evidence level: high/recommenda- goals nationally have not been achieved delivery and enhance maternal safety
tion grade: strong). in terms of reduction of morbidity and have been initiated.116 Additionally, ap-
mortality rates.110 The indications for a proaches to reducing complications in
Comments cesarean delivery have been summarized cesarean delivery have been adopted and
In North America, the most common by the Maternal-Fetal Medicine Unit demonstrated to be impactful.117
indication for admission to the hospital is Network: primary indications (dystocia The focused ERAS CD pathway has
childbirth, and the most common surgery 37%; nonreassuring fetal heart rate 25%; summarized a number of evidenced-
is a cesarean delivery. With this clinical abnormal fetal presentation 20%; other based intraoperative clinical care
volume of obstetric surgical activity, it 15%; failed forceps or vacuum delivery processes. Recommendations for the
seems appropriate that the ERAS process 3%); repeat indications (no vaginal birth scheduled/unscheduled cesarean de-
be applied to this surgical care arena to after cesarean section attempt 82%; livery with the level of evidence and the
improve patient outcomes with the use of failed vaginal birth after cesarean section recommendation grade are summarized
evidence-based approaches. Further, the attempt 17%; failed forceps or vacuum in Table 2. Each of the elements or pro-
impact may be even greater because there delivery 0.4%).111 cesses the focused ERAS CD pathway has
are always 2 patients (mother and fetus) Cesarean delivery has associated risk the opportunity to be measured,
impacted by such care. and benefit profiles for both processes of compared between services/providers,
There are quality industry-based unscheduled or scheduled surgery. and improved as required.
Deming principles that can be directed Complications associated with preg- Elements to consider, for the creation
toward healthcare process management nancy outcomes after a scheduled low- of a clinical audit tool,118 require (1) that
such: quality improvement is the science risk cesarean delivery (46,766 patients) the audited pathway has an important
of process management; if you cannot and planned vaginal birth (2,292,420 impact in terms of costs, resources, or
measure it, you cannot improve it; patients) have been reported in a large risk, (2) that strong scientific evidence is
managed care means managing the cohort study.112 The overall maternal available, and (3) that improvements
processes of care (not the human re- morbidity (cesarean delivery 2.23%; to be made on the topic in question can
sources of care); getting the right data in vaginal birth 0.9%) was not significant be evaluated easily and become a source
the right format at the right time in the for all comparisons.112 Other investi- of important clinical/organizational
right hands; and engaging the human gators have reported a 2-fold increase for consequence(s).
healthcare resources (physicians, nurses, cesarean delivery with an increased The purpose of quality improvement
and other allied health professionals).109 morbidity outcome secondary to puer- is to enhance the safety, efficiency, and
Of course it is important to note that peral infection, hemorrhage, and effectiveness in the multiple areas of the
some significant pregnancy-related fac- thromboembolism.113,114 healthcare process. Surgical healthcare
tors can be measured but cannot be Comparisons of multiple repeat ce- has become a more delegated team sport
modified (Table 3). sarean deliveries has shown that, after with optimized preoperative preparation
The frequency of a cesarean delivery the second repeat cesarean delivery, there (patient education/informed consent),
has increased from 4.5% in 1970 to is an increasing risk for wound and improved surgical process and activity
measurements of the services provided 7. Sullivan SA, Smith T, Chang E, Hulsey T, agents at cesarean delivery. N Engl J Med
(Surgical Safety Checklist/ERAS/ Vandorsten JP, Soper D. Administration of 2016;374:647–55.
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