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Cesarean delivery is a surgical procedure that involves delivering a baby through an abdominal incision (laparotomy) and a uterine incision (hysterotomy). The surgery is typically performed when vaginal birth poses a greater risk to the mother or baby, such as when complications arise during labor in an otherwise planned vaginal delivery or when a condition prevents a vaginal delivery (such as obstruction). Cesarean delivery is considered the most common and safe surgical procedure in the United States. This procedure is often performed for indications such as labor dystocia, fetal distress, abnormal fetal positioning, placental complications, or a history of prior cesarean delivery. However, as a major surgery, cesarean delivery carries risks, including infection, bleeding, and longer recovery times compared to vaginal births. Despite these potential risks, cesarean delivery remains a life-saving intervention in certain medical situations. Decisions made during cesarean delivery can have lasting effects on women and their families. This activity reviews the indications for cesarean delivery, surgical techniques, preoperative and postoperative care, and the management of potential complications, emphasizing the role of a skilled medical team in achieving optimal outcomes for both mother and baby. This activity provides clinicians with a comprehensive understanding of current practices, guidelines, and emerging trends in cesarean delivery, enabling them to enhance patient care and safety. The activity highlights the importance of collaboration among interprofessional healthcare providers, emphasizing how effective teamwork enhances the procedure and improves the health outcomes for women and their newborns. Objectives: Identify the common indications for cesarean delivery, including labor dystocia, fetal distress, abnormal fetal positioning, and placental complications. Implement evidence-based practices in preoperative, intraoperative, and postoperative care to minimize complications and improve patient outcomes. Select optimal surgical approaches and techniques for cesarean delivery based on current evidence, patient-specific factors, and clinical guidelines. Collaborate with obstetricians, anesthesiologists, nurses, and other healthcare providers to develop individualized care plans for each patient undergoing cesarean delivery.

Select optimal surgical approaches and techniques for cesarean delivery based on current evidence, patient-specific factors, and clinical guidelines. Collaborate with obstetricians, anesthesiologists, nurses, and other healthcare providers to develop individualized care plans for each patient undergoing cesarean delivery. Access free multiple choice questions on this topic.

Cesarean delivery is a surgical procedure that involves delivering a baby through an abdominal incision (laparotomy) and a uterine incision (hysterotomy). The first documented cesarean operation occurred in AD 1020, and the procedure has since evolved significantly.[1] Today, cesarean delivery is the most common surgery performed in the United States, with over 1 million women undergoing cesarean deliveries annually. The cesarean delivery rate increased from 5% in 1970 to 31.9% in 2016.[2] This sharp increase can be attributed to various factors, including changes in maternal age, medical advancements allowing more complicated pregnancies to proceed, and evolving obstetric practices. In 2022, the United States recorded more than 3.66 million births, most of which resulted from spontaneous or induced labor. Labor dystocia remains the most common indication for primary cesarean delivery. Globally, cesarean delivery rates continue to rise, and reducing unnecessary cesarean procedures remains a priority in the United States, where 32.2% of all births in 2022 were cesarean deliveries.[3] Despite ongoing efforts to reduce the cesarean rate through initiatives such as promoting vaginal births after cesarean and encouraging natural labor when safe, experts predict that a significant decrease is unlikely for at least another decade.[4] While the procedure carries both immediate and long-term risks, for some women, cesarean delivery may be the safest or even the only option for delivering a healthy newborn.

The maternal mortality rate in the United States is approximately 2.2 per 100,000 cesarean deliveries. Although this rate is relatively low, it is significantly higher than the rate for vaginal deliveries, which is about 0.2 per 100,000.[47] As with any delivery and surgery in general, there is a risk of excessive bleeding during and after a cesarean section. Hemorrhage remains the leading cause of serious maternal morbidity in the United States.[48] Certain conditions preceding a cesarean, such as prolonged labor, fetal macrosomia, or polyhydramnios, may increase the risk of uterine atony and subsequent hemorrhage. Intraoperative factors, such as the need for extensive adhesiolysis or lateral extension of the hysterotomy into the uterine vessels, can contribute to excessive blood loss. Hemorrhage during delivery may necessitate blood product transfusions, which carry their own risk of complications. Approximately 10% of maternal mortality in the United States is due to obstetric hemorrhage.[48] Sheehan syndrome is a known complication that can result from severe hemorrhage during delivery.[48] Infection is a significant risk following cesarean delivery. In addition to postpartum hemorrhage, wound infection and endometritis are common complications after a cesarean delivery. Results from a study examining the efficacy of vaginal cleansing revealed that postoperative endometritis was reduced from 8.7% to 3.8% with cleansing.[26] Additionally, a study investigating the use of adjunctive azithromycin showed a reduction in wound infections from 6.6% to 2.4% with the additional antibiotic and a decrease in severe adverse events from 2.9% to 1.5%.[24] However, given that more than a million women undergo cesarean sections annually, these percentages still represent a significant number of women experiencing infectious complications. Data from 2010 showed that the overall risk of infectious morbidity in elective repeat cesarean deliveries was 3.2%, compared to 4.6% in women undergoing a trial of labor. The same data reported that elective repeat cesarean deliveries had a blood transfusion rate of 0.46%, a surgical injury rate of 0.3% to 0.6%, and a hysterectomy rate of 0.16%.[2] Thromboembolism and anesthetic complications are also potential risks.

Data from 2010 showed that the overall risk of infectious morbidity in elective repeat cesarean deliveries was 3.2%, compared to 4.6% in women undergoing a trial of labor. The same data reported that elective repeat cesarean deliveries had a blood transfusion rate of 0.46%, a surgical injury rate of 0.3% to 0.6%, and a hysterectomy rate of 0.16%.[2] Thromboembolism and anesthetic complications are also potential risks. Although cesarean section is generally safer for the fetus, there are still risks associated with fetal delivery using this approach. The risk of fetal trauma during cesarean delivery is approximately 1% and may include skin lacerations, fractures of the clavicle or skull, facial or brachial plexus nerve damage, and cephalohematoma.[49] Overall, these risks are lower than those associated with vaginal deliveries. However, neonates born via cesarean section face increased risks of respiratory complications, as well as higher rates of asthma and allergies compared to vaginal delivery.[2][50] In 2010, transient tachypnea of the newborn was reported in 4.2% of elective repeat cesarean deliveries, and the need for bag-and-mask ventilation occurred in 2.5% of cases.[2] In addition to short-term surgical risks, cesarean delivery also carries long-term risks for the patient and any subsequent pregnancies. A vertical uterine scar necessitates that future pregnancies be delivered via cesarean section. As the number of cesarean deliveries increases, so do the surgical risks. The formation of adhesions can make each subsequent cesarean more challenging and increase the risk of inadvertent injury. The risks of abnormal placentation increase with each successive cesarean delivery. For a woman who has had one cesarean section, the risk of placenta accreta is 0.3%. However, this risk increases to 6.74% with 5 or more cesarean deliveries.[51] A morbidly adherent placenta carries a risk of significant hemorrhage and may lead to the loss of fertility if a hysterectomy is required.

Effective coordination and communication among interprofessional healthcare team members are essential for ensuring safety and achieving optimal outcomes in cesarean deliveries. Notably, two-thirds of sentinel events are attributed to communication failures.[52] Strategies such as crew resource management, safety bundles, and checklists have been implemented to enhance safety and improve team communication. One critical component is the surgical "time-out," which ensures that everyone in the operating suite is aligned on the procedure details. The Joint Commission mandates a time-out before all procedures to promote patient safety. The Patient Safety Checklist for Planned Cesarean Delivery, developed by the American College of Obstetricians and Gynecologists, exemplifies how checklists can enhance safety. This checklist promotes an interprofessional approach by engaging all healthcare team members, including the surgeon, nurses, anesthesia team, and patient. The checklist addresses key considerations, as listed below. Does the patient have a complete medical history and physical examination? Have known allergies been identified? Does the patient have medical factors affecting anesthetic choices? Has the patient been counseled about risks, benefits, indications, and alternatives? Is the consent form signed? Are appropriate laboratory results available? Has appropriate antibiotic prophylaxis been given? Is appropriate deep vein thrombosis prophylaxis being utilized? Have the fetal heart tones been confirmed? Are there any additional risk factors identified? Bleeding risk Airway Allergies Need for neonatal or pediatric departments Has a time-out been conducted, including identification of the patient, allergies, consent, and surgical procedure, and confirmation of all the team roles? Have surgical counts been performed before the first incision?[53] Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS) is a nationally recognized crew resource management curriculum implemented by numerous healthcare systems.[54][55] The curriculum is an evidence-based framework designed to enhance teamwork, improve care quality, and promote patient safety and efficiency in healthcare settings. A key goal of TeamSTEPPS is to empower every healthcare team member, regardless of their role, to voice concerns when a safety issue arises.

Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS) is a nationally recognized crew resource management curriculum implemented by numerous healthcare systems.[54][55] The curriculum is an evidence-based framework designed to enhance teamwork, improve care quality, and promote patient safety and efficiency in healthcare settings. A key goal of TeamSTEPPS is to empower every healthcare team member, regardless of their role, to voice concerns when a safety issue arises. Feeling intimidated in the workplace is not uncommon, and healthcare is no exception. Intimidation can discourage team members from speaking up, potentially compromising safety. To address this, individuals need tools to actively contribute to a culture of safety. TeamSTEPPS promotes the "CUS" framework—I am Concerned, I am Uncomfortable, This is a Safety issue. Additionally, the use of a "hard stop" serves as a critical safety tool. When invoked, it immediately halts activities, creating an opportunity to communicate and address safety concerns effectively. Simulation training is commonly used to practice team dynamics and identify areas for improvement. Common scenarios for simulation include emergency cesarean sections and postpartum hemorrhages. Through these simulations, roles can be clarified, and communication can be streamlined. Debriefing among the healthcare team is essential for promoting effective communication following a procedure.[56] A debrief helps ensure consistent documentation of the procedure and its details while providing an opportunity for feedback on what went well and areas for improvement. While debriefing can be standard practice after every cesarean, it should be strongly considered following urgent or emergent cases or when complications arise.

Debriefing among the healthcare team is essential for promoting effective communication following a procedure.[56] A debrief helps ensure consistent documentation of the procedure and its details while providing an opportunity for feedback on what went well and areas for improvement. While debriefing can be standard practice after every cesarean, it should be strongly considered following urgent or emergent cases or when complications arise. Implementing the framework for teamwork and communication relies on an interprofessional approach involving physicians, specialty-trained nurses, pharmacists, and other healthcare professionals collaborating across disciplines to achieve optimal patient results. Physicians primarily oversee the surgical procedure, while advanced clinicians and nurses focus on preparing the patient, monitoring intraoperative conditions, and managing postoperative care. Pharmacists ensure accurate medication management, while all healthcare team members are crucial in assessing risks and anticipating complications. By fostering collaboration, shared responsibility, and a commitment to patient-centered care, healthcare teams can enhance outcomes, improve safety, and elevate overall performance in managing cesarean sections.

Nurses play a crucial role throughout the surgical procedure by providing essential preoperative, intraoperative, and postoperative care to patients. They ensure patient safety, monitor vital signs, manage pain, and offer emotional support while collaborating with the surgical team to ensure a smooth and efficient cesarean delivery. Their involvement directly influences both maternal and neonatal outcomes. Similar to how a primary care clinician coordinates a patient's health across various locations and specialties, the nurse serves as a central point of support for the patient during a cesarean delivery. Both childbirth and surgery can cause significant anxiety for patients, and a nurse's ability to reassure and effectively communicate with them has been shown to improve patient satisfaction and reduce stress.[57] During the placement of regional anesthesia, the nurse's presence and support—offering comfort by holding the patient's hands and guiding her through the process—can make a significant difference in the patient's experience. The nurse establishes an initial relationship with the patient preoperatively, often being involved in her care even before an unscheduled cesarean. The nurse may help assist the patient during this time and is responsible for obtaining the patient's medical history and entering it into the electronic health record. Additionally, the nurse ensures that the appropriate labs are collected and verifies the results. Subsequently, the nurse places the indwelling Foley catheter and performs the surgical skin preparation. Once the fetus is delivered, the nurse typically assumes care of the infant and carries out resuscitation if needed. The nurse also serves as the primary communication link between the operating room and those outside. This activity may include providing updates on the surgery's status or responding to inquiries, such as informing someone that the surgeon is occupied. Numerous nursing tasks and actions contribute to the success of a cesarean section.

Nurses play a crucial role during a cesarean section. During the time-out, the nurse must speak up if any essential part of the safety checklist is missing. If the surgeon breaks sterility during the procedure, the nurse may notice and address the issue. Additionally, the nurse is responsible for calling for further assistance if the newborn is not responding well. Nurses also monitor the patient's status postoperatively and report on the following: Maternal vital signs Newborn vital signs Symptoms and/or signs of infection Symptoms and/or signs of breast engorgement Maternal urine output Uterine involution Maternal ambulatory level Wound dressing condition Amount of blood loss Amount of blood and/or serous discharge from the drain, if present