# Cesarean Delivery: Technique, Complications, and Enhanced Recovery

## Indications

### Common Indications

The most common indication for cesarean delivery is labor arrest in the first or second stage. Other indications include non-reassuring fetal heart rate tracing, malpresentation (breech or transverse lie), placenta previa or vasa previa, prior classical or inverted-T uterine incision, active genital herpes outbreak, elective repeat cesarean delivery, and placenta accreta spectrum requiring planned cesarean hysterectomy.

### Emergent vs. Urgent vs. Scheduled

Emergent (crash) cesarean delivery addresses an immediate threat to maternal or fetal life, such as cord prolapse, uterine rupture, or massive hemorrhage, with a target decision-to-incision time of less than 30 minutes. Urgent cesarean delivery addresses fetal distress without immediate life threat and allows brief preparation. Scheduled or elective cesarean delivery is performed for planned repeat cesarean, malpresentation, or maternal request, typically at 39 weeks.

## Preoperative Preparation

### Antibiotic Prophylaxis

Cefazolin 2 g IV (or 3 g if the patient weighs 120 kg or more) is administered within 60 minutes before skin incision. For unscheduled cesareans performed during labor, azithromycin 500 mg IV is added, which reduces endometritis and wound infection as demonstrated by the C/SOAP trial. For patients with penicillin allergy, clindamycin 900 mg plus gentamicin 5 mg/kg is substituted.

### Other Preparations

Additional preoperative measures include antacid prophylaxis with sodium citrate 30 mL orally or IV ranitidine/famotidine, Foley catheter placement, type and screen (crossmatch if there is a high risk of hemorrhage), surgical time-out and safety checklist, antiemetic administration (ondansetron 4 mg IV) at the surgeon's request or with spinal anesthesia, and placement of sequential compression devices before spinal placement for thromboprophylaxis.

## Anesthesia

### Neuraxial (Preferred)

Spinal anesthesia involves a single injection with rapid onset of 3 to 5 minutes, achieving a T4 block level for cesarean. An existing epidural placed during labor can be dosed incrementally for cesarean, with a slower onset. Combined spinal-epidural (CSE) provides the spinal for immediate effect with an epidural catheter for prolonged or additional dosing. Benefits of neuraxial anesthesia include the patient remaining awake, lower aspiration risk, and the partner being able to be present.

### General Anesthesia

General anesthesia is indicated when neuraxial anesthesia fails, when an emergent cesarean does not allow time for a block, when the patient refuses neuraxial anesthesia, or in the presence of severe coagulopathy. Risks include difficult intubation, aspiration (managed with rapid-sequence induction), and neonatal sedation. Preoxygenation, cricoid pressure, and a rapid-sequence intubation protocol are employed.

<image>Cross-sectional diagram of the anterior abdominal wall layers encountered during cesarean delivery, from skin through subcutaneous fat, Camper and Scarpa fascia, rectus sheath (anterior and posterior), rectus abdominis muscle, transversalis fascia, preperitoneal fat, peritoneum, and uterus</image>

## Surgical Technique

### Skin Incision

The Pfannenstiel incision is a transverse suprapubic incision made 2 to 3 cm above the symphysis pubis. It is the most commonly used approach and offers better cosmetic results, less postoperative pain, and lower hernia risk. The Joel-Cohen incision is a straight transverse incision placed slightly higher than the Pfannenstiel, with blunt dissection favored, and is used in enhanced recovery protocols. A vertical midline incision is used for emergent cases, extreme obesity, extensive adhesions, or the need for surgical exploration, as it provides the fastest entry to the peritoneal cavity.

### Layer-by-Layer Approach (Pfannenstiel)

The procedure begins with a sharp skin incision, followed by sharp or blunt dissection through subcutaneous tissue. The rectus fascia is incised transversely and extended laterally with Mayo scissors. The rectus muscles are separated in the midline by blunt dissection. The peritoneum is entered bluntly with a high entry to avoid the bladder. A bladder flap is created by incising the vesicouterine peritoneum and reflecting the bladder inferiorly, though some surgeons omit this step based on evidence that it is not always necessary and adds operative time. The hysterotomy is made as a low transverse (Kerr) incision with sharp entry and blunt extension laterally and cephalad, avoiding sharp lateral extension to reduce the risk of uterine artery laceration. After delivery of the infant, cord clamping is performed with a delay of 30 to 60 seconds for term infants. The placenta is delivered with spontaneous expulsion and gentle cord traction, which is preferred over manual extraction because manual extraction increases the risk of endometritis.

### Uterine Closure

Single-layer closure is faster and adequate for most cases, using a running locked or unlocked suture. Double-layer closure may reduce the risk of uterine scar dehiscence in future pregnancies and is preferred when future VBAC is planned. The first layer is a full-thickness running locked suture, and the second layer imbricates the first. Absorbable suture (0 or 1-0 polyglactin or poliglecaprone) is used. Hemostasis is ensured at the angles, with additional figure-of-eight sutures placed as needed.

### Closure

Peritoneal closure is not required, as the peritoneum reapproximates spontaneously, and closure adds time and may increase adhesion formation. The rectus fascia is closed with a continuous running suture using delayed absorbable material (0 polyglactin or PDS). Subcutaneous tissue is closed if the depth is 2 cm or greater to reduce wound complications. Skin is closed with subcuticular suture (which has a lower wound complication rate than staples, particularly in obese patients) or staples.

## Intraoperative Complications

### Hemorrhage

Uterine atony is the most common cause of hemorrhage at cesarean delivery. Management follows a uterotonic cascade: oxytocin, then methylergonovine, then carboprost, then misoprostol. Surgical options include compression sutures (B-Lynch), uterine artery ligation, and hysterectomy. Extension of the hysterotomy into uterine vessels is managed with figure-of-eight sutures.

### Bladder Injury

The risk of bladder injury is increased with prior cesarean (due to adhesions), emergent entry, and failure to adequately reflect the bladder. It is recognized by clear fluid in the operative field, visible bladder wall injury, or cystoscopy findings. Repair involves two-layer closure with absorbable suture, and the Foley catheter is left in place for 7 to 14 days. Intraoperative cystoscopy should be considered if injury is suspected.

### Bowel Injury

Bowel injury is rare but has increased risk with extensive adhesions. Repair is performed by the appropriate surgical service with intraoperative consultation as needed.

### Ureteral Injury

Ureteral injury is rare during cesarean but more common during cesarean hysterectomy. The risk increases with low lateral extension of the hysterotomy or aggressive hemostatic sutures. Cystoscopy with indigo carmine confirms ureteral patency when injury is suspected.

<image>Intraoperative view illustration of a low transverse cesarean hysterotomy showing the bladder flap reflected inferiorly, the uterine incision extended laterally with blunt technique, and the relationship of the uterine arteries at the lateral margins of the incision</image>

## Enhanced Recovery After Cesarean (ERAC)

### Preoperative

The preoperative component includes patient education and expectation setting, clear liquids up to 2 hours before surgery and a light meal up to 6 to 8 hours before, carbohydrate loading drink for non-diabetic patients, and minimized fasting time.

### Intraoperative

Intraoperative measures include multimodal analgesia with neuraxial morphine (intrathecal or epidural) and bilateral TAP block or QL block if neuraxial opioid is not used, IV acetaminophen and ketorolac, antiemetic prophylaxis, maintenance of normothermia with forced-air warming, goal-directed fluid therapy avoiding fluid overload, and surgical efficiency techniques such as Joel-Cohen entry, omitting the bladder flap, and single-layer closure.

### Postoperative

Postoperative care includes early oral intake within 2 to 4 hours, early ambulation within 6 to 8 hours, early Foley catheter removal within 6 to 12 hours, and scheduled multimodal analgesia (acetaminophen 1 g every 6 hours, ibuprofen 600 mg every 6 hours, with opioids reserved for PRN use only). VTE prophylaxis includes sequential compression devices and early mobilization, with pharmacologic prophylaxis for high-risk patients. Skin-to-skin contact in the operating room (if the patient is stable) and early breastfeeding initiation are encouraged.

| Phase | Component | Details |
|---|---|---|
| Preoperative | Fasting | Clear liquids up to 2 hours; light meal up to 6-8 hours |
| Preoperative | Carbohydrate loading | Non-diabetic patients |
| Intraoperative | Analgesia | Neuraxial morphine; TAP/QL block if no neuraxial opioid; IV acetaminophen + ketorolac |
| Intraoperative | Normothermia | Forced-air warming |
| Intraoperative | Surgical efficiency | Joel-Cohen entry, omit bladder flap, single-layer closure |
| Postoperative | Oral intake | Within 2-4 hours |
| Postoperative | Ambulation | Within 6-8 hours |
| Postoperative | Foley removal | Within 6-12 hours |
| Postoperative | Analgesia | Acetaminophen 1 g q6h + ibuprofen 600 mg q6h; opioids PRN only |
| Postoperative | VTE prophylaxis | SCDs + early mobilization; pharmacologic if high-risk |

### Outcomes with ERAS

Enhanced recovery protocols reduce opioid consumption by 40 to 70%, accelerate return of bowel function, shorten length of stay (with average discharge on postoperative day 2 instead of day 3), and achieve high patient satisfaction without increasing complications or readmissions.

## Postoperative Complications

### Wound Complications

Surgical site infection occurs in 3 to 8% of cases, with higher rates in patients with obesity, diabetes, or prolonged labor. Other wound complications include dehiscence or separation, seroma, hematoma, and necrotizing fasciitis (rare but life-threatening). Prevention strategies include appropriate antibiotic prophylaxis, subcutaneous tissue closure, proper skin closure technique, and negative pressure wound therapy for high-risk patients.

### Endometritis

Postpartum intrauterine infection occurs in 5 to 10% of cesarean deliveries (higher without prophylactic antibiotics). It presents with fever, uterine tenderness, and purulent lochia. Treatment consists of IV clindamycin plus gentamicin, or ampicillin/sulbactam.

### Venous Thromboembolism

The risk is increased after cesarean compared to vaginal delivery. Prevention includes early ambulation, sequential compression devices, and pharmacologic prophylaxis for high-risk patients.

### Ileus

Ileus is uncommon with ERAS protocols. Early feeding and ambulation are preventive. Severe cases are managed with bowel rest and nasogastric decompression.

## Clinical Pearls

Azithromycin added to cefazolin for unscheduled cesareans during labor significantly reduces infectious complications, as demonstrated by the C/SOAP trial.

Blunt extension of the hysterotomy reduces the risk of uterine vessel laceration compared to sharp extension.

Double-layer uterine closure may be preferred for patients planning future VBAC, though evidence is not definitive.

Peritoneal closure is unnecessary and may increase adhesion formation.

ERAS protocols reduce opioid use by 40 to 70% and shorten hospital stay without increasing complications.

Gentle cord traction for placental delivery is preferred over manual removal to reduce the risk of endometritis.

Subcuticular skin closure has lower wound complication rates than staples, especially in obese patients.

The crash cesarean for cord prolapse or uterine rupture should target decision-to-delivery within 30 minutes. Drills and practice improve team performance.

## References

- ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery (2019) -- surgical technique discussion
- Tita ATN et al. Adjunctive azithromycin prophylaxis for cesarean delivery (C/SOAP). N Engl J Med. 2016;375:1228-1237
- Macones GA et al. Society for Maternal-Fetal Medicine: Enhanced Recovery After Cesarean (2019)
- ACOG Committee Opinion No. 750: Perioperative Pathways: Enhanced Recovery After Surgery (2018)
- Dahlke JD et al. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013
- Tuuli MG et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med. 2016