Techniques For Caesarean Section Jan 2023 PDF

Techniques for
Caesarean Section
Author: Labour Ward Forum

Date Approved : 25.1.2023
Approved by: : Labour ward Forum
Date for Review: 25.1.2026
Purpose of the Guideline
Rates of caesarean section (CS) have been rising globally. It is important to use the
most effective and safe technique.
The following recommendations for surgical techniques apply to pregnancies at term

where there is a lower uterine segment. Techniques may need modification in
situations such as repeat CS, placenta praevia or very pre-term pregnancies.
General recommendations
• Safe surgical practice should be followed at CS to reduce the risk of blood borne
infections of staff. Health Care professionals should follow the Health Board
Policy on universal protection for infection control
• The mother should have a lateral tilt of 15°until delivery of the baby, because
this reduces maternal hypotension
• Cleansing the vagina immediately before a caesarean delivery with either an

iodine-based or chlorhexidine based solution probably reduces the risk of
infection of the uterus after a caesarean section. This benefit may be greater
for women who have their caesarean delivery after their membranes have
already ruptured or they are already in labour. This is a generally simple, well
tolerated way to lower the chances of developing an infection after having a
baby by caesarean. Cochrane review, July 2018; NICE guideline [NG192]
• Maternal bladder should be catheterised with Foley’s catheter

• If there is a need for hair removal clippers should be used – shaving of hair with
razor blade is not recommended
• Use Chloraprep for skin disinfection – refer to appendix 1 “Using Chloraprep”
• Antibiotic prophylaxis to be given prior to skin incision.
Techniques for Caesarean Section
• CS should be performed using a transverse abdominal incision because this is

associated with less postoperative pain and an improved cosmetic effect
compared with a midline incision
• The transverse incision of choice should be the Joel Cohen incision (a 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),
because it is associated with shorter operating times and reduced postoperative
febrile morbidity compared to Pfannenstiel incision (curved skin incision, two-
fingers breadths above the symphysis pubis, transverse incision of the sheath,
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rectus muscles are separated bluntly and the parietal peritoneum is incised is
the midline).
• The use of separate surgical knives to incise the skin and the deeper tissues at
CS is not recommended because it does not decrease wound infection.
• Great caution should be taken while incising the uterine wall and the amniotic
membrane to avoid fetal lacerations (2% risk of fetal laceration during CS)
particularly in presence of thin uterine wall, ruptured membranes and anterior
placenta previa where bleeding could obscure vision. Consideration should be
given to using blunt instruments. When there is a well formed lower uterine
segment, blunt rather than sharp extension of the uterine incision should be
used as it reduces blood loss, incidence of postpartum haemorrhage, and the
need for transfusion at CS.
• Wrigley’s Forceps should only be used at CS if there is difficulty delivering the

baby's head. (The effect on neonatal morbidity of the routine use of forceps at
CS remains uncertain).
• If head is deeply engaged, follow ‘Management Impacted Fetal Head at

Caesarean section’ algorithm: Appendix 2 (Algorithms 1-4)
• Delay cord clamping by 1 minute (in absence of fetal compromise). Double

clamp the cord.
• Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage

contraction of the uterus and to decrease blood loss. Tranexamic acid 1 gm in
addition is recommended in presence of risk factors for PPH.
• The placenta should be removed using controlled cord traction and not manual
removal as this reduces the risk of endometritis.
• Ensure placenta is removed completely.
• Intra-abdominal repair of the uterus at CS should be undertaken. Exteriorisation

of the uterus routinely is not recommended because it is associated with
maternal nausea/vomiting and more pain, and does not improve operative
outcomes such as haemorrhage and infection
• There is not enough evidence to recommend either single layer or double layer
closure
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• Neither the visceral nor the parietal peritoneum should be sutured at CS
because this reduces operating time and the need for postoperative analgesia
and improves maternal satisfaction
• If inserting a peritoneal drain in rare cases use a No.16 drain without suction
• In the rare circumstances that a midline abdominal incision is used at CS, mass
closure with slowly absorbable continuous sutures (like PDS) should be used
because this results in fewer incisional hernias and less dehiscence than
layered closure
• Routine closure of the subcutaneous tissue space should not be used, unless
the woman has more than 2 cm subcutaneous fat or is very thin (to avoid skin
puckering down onto the rectus sheath)
• Superficial wound drains should not be used at CS because they do not

decrease the incidence of wound infection or wound haematoma
• Skin incision should preferably be closed with subcutaneous stitches with a

dissolvable monofilament suture material (but the effects of different suture
materials or methods of skin closure at CS are not certain). Consider using
interrupted sutures with curved needle in women with blood-borne infections.
Use of staples is not advisable as it is associated with increased wound
infection and wound dehiscence. NICE Guideline NG192
• If pressure dressing has been applied, it should be removed within 6 hours and
wound assessed
• Consider PICO (negative pressure) dressing in women with BMI > 40 or in

presence of other risk factors like diabetes, previous wound infection.
• Umbilical artery pH should be performed after all CS for suspected fetal

compromise, to allow review of fetal well-being and guide ongoing care of the
baby
• Women having a CS should be offered prophylactic antibiotics prior to sken

incision, as per local microbiology guidelines, to reduce the risk of postoperative
infections (such as endometritis, urinary tract and wound infection), which occur
in about 8% of women who have had a CS
• Women having a CS should have a VTE risk assessment. The choice of method
of prophylaxis (for example, graduated stockings, hydration, early mobilisation,
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low molecular weight heparin) should take into account their risk of
thromboembolic disease and follow existing guidelines.
• Where regional anaesthesia has been used, indwelling catheter should be

removed after 12 hours post operatively.
References:
• Abdominal surgical incisions for caesarean section. Cochrane Database Syst

Rev. 2007 Jan 24; (1):CD004453. Epub 2007 Jan 24. [Cochrane Database Syst
Rev. 2007]
• Techniques for caesarean section. Cochrane Database Syst Rev. 2008 Jan 23;
(1):CD004662. Epub 2008 Jan 23. [Cochrane Database Syst Rev. 2008]
• Methods of delivering the placenta at caesarean section. Cochrane Database

Syst Rev. 2008 Jul 16; (3):CD004737. Epub 2008 Jul 16. [Cochrane Database
Syst Rev. 2008]
• Surgical techniques for uterine incision and uterine closure at the time of
caesarean section. Cochrane Database Syst Rev. 2008 Jul 16;
(3):CD004732. Epub 2008 Jul 16. [Cochrane Database Syst Rev. 2008]
• Extra-abdominal versus intra-abdominal repair of the uterine incision at

caesarean section. Cochrane Database Syst Rev. 2004 Oct 18;
(4):CD000085. Epub 2004 Oct 18. [Cochrane Database Syst Rev. 2004]
• National Collaborating Centre for Women's and Children's Health. Caesarean

section. London (UK): National Institute for Clinical Excellence (NICE); 2004
Apr.
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Maternity Services
Checklist for Clinical Guidelines being Submitted for Approval
Title of Guideline: Techniques for Caesarean Section
Name(s) of Author: Madhuchanda Dey
Chair of Group or Committee Labour Ward Forum

approving submission:
Brief outline giving reasons for It is important to use the most effective and safe
document being submitted for technique. This document gives recommendations
ratification for surgical techniques for term pregnancies with a
lower uterine segment.
Details of persons included in Consultant Obstetricians, Labour Ward Forum

consultation process: membership
Name of Pharmacist N/A
(mandatory if drugs involved):
Issue/Version No: 2
Please list any policies/guidelines Techniques for Caesarean Section

this document will supercede:
Date approved by Group: 25th January 2023
Next Review / Guideline Expiry: 25th January 2026
Please indicate key words you Technique, CS, Caesarean

wish to be linked to document:
File Name: Used to locate where Z:\npt_fs2\Maternity Incidents Stats

file is stores on hard drive Etc\Policies\Ratified - Obs
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Techniques for

Author: Labour Ward Forum

The following recommendations for surgical techniques apply to pregnancies at term

• Cleansing the vagina immediately before a caesarean delivery with either an

• Maternal bladder should be catheterised with Foley’s catheter

• Use Chloraprep for skin disinfection – refer to appendix 1 “Using Chloraprep”

• Antibiotic prophylaxis to be given prior to skin incision.

Techniques for Caesarean Section

• CS should be performed using a transverse abdominal incision because this is

• Wrigley’s Forceps should only be used at CS if there is difficulty delivering the

• If head is deeply engaged, follow ‘Management Impacted Fetal Head at

• Delay cord clamping by 1 minute (in absence of fetal compromise). Double

• Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage

• Ensure placenta is removed completely.

• Intra-abdominal repair of the uterus at CS should be undertaken. Exteriorisation

• Superficial wound drains should not be used at CS because they do not

• Skin incision should preferably be closed with subcutaneous stitches with a

• Consider PICO (negative pressure) dressing in women with BMI > 40 or in

• Umbilical artery pH should be performed after all CS for suspected fetal

• Women having a CS should be offered prophylactic antibiotics prior to sken

• Where regional anaesthesia has been used, indwelling catheter should be

• Abdominal surgical incisions for caesarean section. Cochrane Database Syst

• Methods of delivering the placenta at caesarean section. Cochrane Database

• Extra-abdominal versus intra-abdominal repair of the uterine incision at

• National Collaborating Centre for Women's and Children's Health. Caesarean

Checklist for Clinical Guidelines being Submitted for Approval

Title of Guideline: Techniques for Caesarean Section

Name(s) of Author: Madhuchanda Dey

Chair of Group or Committee Labour Ward Forum

Details of persons included in Consultant Obstetricians, Labour Ward Forum

Name of Pharmacist N/A

(mandatory if drugs involved):

Please list any policies/guidelines Techniques for Caesarean Section

Date approved by Group: 25th January 2023

Next Review / Guideline Expiry: 25th January 2026

Please indicate key words you Technique, CS, Caesarean

File Name: Used to locate where Z:\npt_fs2\Maternity Incidents Stats

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