Preoperative preparation of the abdominal wall skin is efective to prevent wound infection. Either chlorhexidine or povidone-iodine solutions are suitable (Hadiati, 2014; Ngai, 2015; Springel, 2017). In studies that found a diference, chlorhexidine was favored, and this is our practice (Menderes, 2012; Tuuli, 2016a). In addition, preoperative vaginal cleansing with a povidone-iodine scrub has been evaluated in small randomized trials (Haas, 2014; Caissutti, 2017). Some showed lower rates of metritis, especially for those with ruptured membranes or active labor, but not lower rates of wound infection (Haas, 2010; Memon, 2011; Yildirim, 2012). Some recommend preoperative vaginal cleansing, bur we do not do this at Parkland Hospital.
Antibiotic prophylaxis against infective endocarditis is not recommended for most cardiac conditions-exceptions are women with cyanotic heart disease, prosthetic valves, or both (American College of Obstetricians and Gynecologists, 2016). Regimens selected for routine cesarean infection prophylaxis will also serve as appropriate endocarditis coverage (Chap. 49, p. 965).
Glycemic control in diabetics lowers wound infection rates and is emphasized in Chapter 57 (p. 1105). Smoking is another modiiable risk, and its mitigation is especially helpful for morbidly obese women (Alanis, 2010; Avila, 2012; Shree, 2016). Intraoperative normothermia lowers wound infection rates in general surgery and is a Surgical Care Improvement Project measure (Kurz, 1996; he Joint Commission, 2016). his tenet might logically be extrapolated to cesarean delivery, although deinitive studies are lacking (Carpenter, 2012). Perioperative supplementation with high-concentration inspired oxygen does not lower wound infection rates (Duggal, 2013; Klingel, 2013).
he Joint Commission (2013) established a protocol to prevent surgical errors. For cesarean delivery, all relevant documents are veriied immediately before surgery, and a "time out" is completed. The "time out" requires attention of the entire team to confirm that the patient, site, and procedure are correct. Important discussions also include introduction of the patient-care team members, veriication of prophylactic antibiotics, estimation of procedure length, and communication of anticipated complications. Additionally, requests for special instrumentation should be addressed preoperatively to prevent potential patient compromise and intraoperative delays.
An instrument, sponge, and needle count before and after surgery is crucial to surgical safety. If counts are not reconciled, radiographic imaging for retained foreign objects is obtained (American College of Obstetricians and Gynecologists, 20 14a).
With minor variations, surgical performance of cesarean delivery is comparable worldwide. Most steps are founded on evidence-based data, and these have been reviewed by Dahlke and associates (2013). As with all surgery, a clear understanding of relevant anatomy is essential, and this is described and illustrated in Chapter 2 (p. 14).
In obstetrics, a suprapubic transverse incision or a midline vertical one is chosen for laparotomy. Transverse abdominal entry is by either Pfannenstiel or Maylard incisions. Of all these, the Pfannenstiel incision is selected most frequently for cesarean delivery.
Transverse incisions follow Langer lines of skin tension.