Guideline sources The following summarized guidelines for the management of cesarean delivery are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022; 2021; 2020; 2018; 2017), the American College of Obstetricians and Gynecologists (ACOG 2021; 2020; 2019; 2018; 2017), the American Heart Association (AHA 2020), the Royal College of Obstetricians and Gynaecologists (RCOG 2019; 2015; 2012), the Enhanced Recovery After Surgery Society (ERASS 2018), the World Health Organization (WHO 2018; 2015), the Society for Maternal-Fetal Medicine (SMFM 2015), the American College of Obstetricians and Gynecologists (ACOG/SMFM 2014), and the American College of Chest Physicians (ACCP 2012). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Guidelines 1. Perioperative care Preoperative antibiotic prophylaxis: As per ERASS 2018 guidelines, administer IV antibiotics routinely within 60 minutes before the Cesarean delivery skin incision. Administer a first-generation cephalosporin in all females. Consider adding azithromycin for additional reduction in postoperative infections in females in labor or with ruptured membranes. A https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 1/8 6/29/23, 3:50 AM Cesarean delivery Pathway As per SOGC 2017 guidelines, administer antibiotic prophylaxis (a single dose of a first- generation cephalosporin, or clindamycin or erythromycin in case of penicillin allergy) 15-60 minutes before skin incision in all females undergoing elective or emergency Cesarean delivery. A Show 3 more As per WHO 2015 guidelines: Administer routine antibiotic prophylaxis (before skin incision rather than intraoperatively after umbilical cord clamping) in females undergoing elective or emergency Cesarean delivery. B Administer a single dose of first-generation cephalosporin or penicillin in preference to other classes of antibiotics for antibiotic prophylaxis. B Perioperative thromboprophylaxis: discontinue LMWH at least 24 hours before Cesarean delivery (or expected time of neuraxial anesthesia) in females receiving adjusted-dose LMWH therapy. B Show 4 more Perioperative fluid management: ensure preoperative and intraoperative euvolemia for improved maternal and neonatal outcomes after Cesarean delivery. B Intraoperative prevention of hypothermia: Obtain appropriate body temperature monitoring to apply warming devices and avoid hypothermia. B Apply forced-air warming, administer intravenous uid warming, and increase operating room temperature to prevent hypothermia during Cesarean delivery. B 2. Surgical interventions Indications for Cesarean delivery, macrosomia: as per RCOG 2012 guidelines, perform elective Cesarean delivery to reduce the potential morbidity for pregnancies complicated by preexisting or gestational diabetes, regardless of treatment, with an estimated fetal weight of > 4,500 g. B Indications for Cesarean delivery, vasa previa: As per RCOG 2019 guidelines, do not delay delivery while trying to confirm the diagnosis, particularly if there is evidence that fetal wellbeing is compromised, because of the speed at which fetal exsanguination can occur and the high perinatal mortality rate associated with ruptured vasa previa. D Show 5 more As per SOGC 2017 guidelines: Offer elective Cesarean delivery before the onset of labor if vasa previa is diagnosed antenatally. B Perform Cesarean delivery in a birthing unit with continuous electronic fetal HR monitoring and a rapid biochemical test for fetal Hgb, obtained as soon as possible if time permits, in case of bleeding or premature rupture of membranes. Perform urgent Cesarean delivery if any of the tests are abnormal. B https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 2/8 6/29/23, 3:50 AM Cesarean delivery Pathway As per SMFM 2015 guidelines, perform Cesarean delivery if a patient with pregnancy at viable gestational age has an antenatal diagnosis of vasa previa and then develops premature rupture of membranes or labor. B Show 2 more Indications for Cesarean delivery, placenta previa: As per SOGC 2020 guidelines: Offer Cesarean delivery in patients with placenta previa at 36+0 to 36+6 weeks of gestation in the presence of risk factors and at 37+0 to 37+6 weeks of gestation in the absence of risk factors. B Offer Cesarean delivery in patients with a low-lying placenta with the placental edge 10 mm from the cervical os at 37+0 to 37+6 weeks of gestation in the presence of risk factors and at 38+0 to 38+6 weeks of gestation in the absence of risk factors. B As per RCOG 2019 guidelines, ensure that a planned Cesarean delivery in patients with placenta previa is performed by an appropriately experienced surgeon, and a senior obstetrician (usually a consultant) and senior anesthetist (usually a consultant) are present within the delivery or theater suite. Alert senior obstetrician and senior anesthetist immediately to attend urgently if an emergency arises. B Show 5 more Indications for Cesarean delivery (placenta accrete): prefer performing Cesarean delivery hysterectomy with the placenta left in situ over attempting to separate it from the uterine wall. B Indications for Cesarean delivery, resuscitative hysterotomy: as per AHA 2020 guidelines, consider preparing to evacuate the uterus while continuing resuscitation if the pregnant patient in cardiac arrest with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement. B Show 2 more Indications for Cesarean delivery, maternal request: as per ACOG 2019 guidelines, offer vaginal delivery in the absence of maternal or fetal indications for Cesarean delivery. E Show 2 more Choice of anesthesia: administer regional anesthesia as the preferred method of anesthesia for Cesarean delivery as part of an enhanced recovery protocol. B Technical considerations for Cesarean delivery, field preparation: As per ERASS 2018 guidelines: Prefer chlorhexidine-alcohol over aqueous povidone-iodine solution for abdominal skin cleansing before Cesarean delivery. B Consider cleansing the vagina with povidone-iodine solution for the reduction of infections after Cesarean delivery. C As per WHO 2015 guidelines: Perform vaginal cleansing with povidone-iodine immediately before skin incision. B Decide on the choice of an antiseptic agent and its method of application based primarily on the clinician's experience with that particular antiseptic agent and method of application, cost, https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 3/8 6/29/23, 3:50 AM Cesarean delivery Pathway and local availability. B Technical considerations for Cesarean delivery (incision): perform blunt expansion of the transverse uterine incision to reduce surgical blood loss. B Technical considerations for Cesarean delivery (closure): suture the uterine incision in two layers to lower the rate of uterine rupture. B Show 3 more 3. Preventative measures Primary prevention of Cesarean delivery (first stage of labor): do not perform Cesarean delivery based on a prolonged latent phase (such as > 20 hours in nulliparous females and > 14 hours in multiparous females). D Show 3 more Primary prevention of Cesarean delivery (second stage of labor): insufficient evidence to recommend a specific absolute maximum length of time spent in the second stage of labor beyond which all females should undergo operative delivery. I Show 3 more Primary prevention of Cesarean delivery (fetal conditions): limit Cesarean delivery (to avoid potential birth trauma) to estimated fetal weights of at least 5,000 g in females without diabetes and at least 4,500 g in females with diabetes. Counsel females that estimates of fetal weight, particularly late in gestation, are imprecise as the prevalence of birth weight of 5,000 g is rare. B Show 3 more Primary prevention of Cesarean delivery (maternal factors): counsel females about the IOM maternal weight guidelines in an attempt to avoid excessive weight gain. B Primary prevention of Cesarean delivery (twin gestation): counsel females with either cephalic/cephalic-presenting twins or cephalic/non-cephalic presenting twins to attempt vaginal delivery as perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by Cesarean delivery. B Primary prevention of Cesarean delivery (policies): ensure that individuals, organizations, and governing bodies work to conduct research to provide a better knowledge base to guide decisions regarding Cesarean delivery and to encourage policy changes that safely lower the rate of primary Cesarean delivery. B Primary prevention of Cesarean delivery (induction of labor): do not perform routine induction of labor based on maternal and fetal medical indications before 41+0 weeks of gestation. Perform inductions at 41+0 weeks of gestation to reduce the risk of Cesarean delivery and the risk of perinatal morbidity and mortality. D Show 2 more https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 4/8 6/29/23, 3:50 AM Cesarean delivery Pathway 4. Follow-up and surveillance Immediate care of the newborn at delivery, cord clamping: As per SOGC 2022 guidelines, delay cord clamping for 60-120 seconds in both preterm (< 37 weeks) and extremely preterm (< 28 weeks) singletons because it decreases newborn mortality and morbidity and improves hematological outcomes after the neonatal period. Delay cord clamping for at least 30 seconds over clamping immediately when cord clamping cannot be deferred for a full 60-120 seconds. Delay cord clamping with the infant at the level of the Cesarean incision. A Show 5 more As per ERASS 2018 guidelines, delay cord clamping for at least 1 minute at term deliveries B and for at least 30 seconds at preterm deliveries. B As per WHO 2018 guidelines, delay umbilical cord clamping ( 1 minute after birth) for improved maternal and infant health and nutrition outcomes. A Immediate care of the newborn at delivery (supportive care): measure body temperature and maintain it at 36.5-37.5 C after birth, through admission and stabilization. B Show 3 more Immediate care of the newborn at delivery (vaginal seeding): do not perform or encourage vaginal seeding outside of the context of an IRB-approved research protocol until adequate data regarding the safety and benefit of the process become available. D Show 2 more Vaginal birth after Cesarean delivery, indications for trial of labor: As per ACOG 2017 guidelines, offer a trial of labor after Cesarean delivery in most females with one previous Cesarean delivery with a low transverse incision. A Show 5 more As per RCOG 2015 guidelines, implement a vaginal birth after previous Cesarean delivery versus elective repeat C-section checklist or clinical care pathway to facilitate best practice in antenatal counseling, shared decision-making, and documentation. B Show 8 more As per RCOG 2012 guidelines, offer either vaginal or Cesarean delivery, based on a joint decision by the female and her physician, in females with a previous delivery complicated with shoulder dystocia. B Vaginal birth after Cesarean delivery, setting of care: As per ACOG 2017 guidelines, perform a trial of labor after Cesarean delivery at facilities capable of performing emergency deliveries. Manage females attempting a trial of labor after Cesarean delivery in a level I center (one that can provide basic care) or higher. B Show 3 more As per RCOG 2015 guidelines, conduct a planned vaginal birth after previous Cesarean delivery in a suitably staffed and equipped delivery suite with continuous intrapartum care and monitoring https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 5/8 6/29/23, 3:50 AM Cesarean delivery Pathway with resources available for immediate Cesarean delivery and advanced neonatal resuscitation. B Vaginal birth after Cesarean delivery (antenatal counseling): document the antenatal counseling in the notes. B Show 6 more Vaginal birth after Cesarean delivery, technical considerations: As per ACOG 2017 guidelines, consider administering induction of labor as an option in females undergoing a trial of labor after Cesarean delivery. C Show 4 more As per RCOG 2015 guidelines, inform females of the 2- to 3-fold increased risk of uterine rupture and around 1.5-fold increased risk of Cesarean delivery in induced and/or augmented labor compared with spontaneous vaginal birth after previous Cesarean delivery. B Show 7 more Management of Cesarean scar pregnancy: Consider performing hysteroscopy for surgical management of patients with type 1 Cesarean scar pregnancy. C Consider performing laparoscopy for surgical management of patients with type 2 Cesarean scar pregnancy. C Studies 2021 TRAAP2 In women undergoing Cesarean delivery at 34 gestational weeks, tranexamic acid was superior to placebo with respect to postpartum hemorrhage. Lo c Sentilhes et al. N Engl J Med. 2021 Apr 29. 2016 C/SOAP In women with a singleton pregnancy with a gestation of 24 weeks who were undergoing Cesarean delivery during labor or after membrane rupture, azithromycin was superior to placebo with respect to the rate of composite of endometriosis, wound infection, or other infection occurring within 6 weeks. Alan T N Tita et al. N Engl J Med. 2016 Sep 29. References 1. American College of Obstetricians and Gynecologists College), Society for Maternal-Fetal Medicine, Aaron B Caughey et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210 3 179 93. Open https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 6/8 6/29/23, 3:50 AM Cesarean delivery Pathway 2. Julie van Schalkwyk, Nancy Van Eyk. No. 247 Antibiotic Prophylaxis in Obstetric Procedures. J Obstet Gynaecol Can. 2017 Sep;39 9):e293-e299. Open 3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 761 Cesarean Delivery on Maternal Request. Obstet Gynecol. 2019 Jan;133 1):e73-e77. Open 4. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199 Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol. 2018 Sep;132 3):e103-e119. Open 5. No authors listed. Practice Bulletin No. 184 Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2017 Nov;130 5):e217-e233. Open 6. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 7. Aaron B Caughey, Stephen L Wood, George A Macones et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations Part 2 . Am J Obstet Gynecol. 2018 Dec;219 6 533 544. Open 8. R Douglas Wilson, Aaron B Caughey, Stephen L Wood et al. Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations Part 1 . Am J Obstet Gynecol. 2018 Dec;219 6 523.e1 523.e15. Open 9. Erm Jauniaux, Z Alfirevic, A G Bhide et al. Vasa Praevia: Diagnosis and Management: Green-top Guideline No. 27b. BJOG. 2019 Jan;126 1):e49-e61. Open 10. American College of Obstetricians and Gynecologists Committee on Practice Bulletins Obstetrics. Obesity in Pregnancy: ACOG Practice Bulletin, Number 230. Obstet Gynecol. 2021 Jun 1;137 6):e128-e144. Open 11. Royal College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Birth. RCOG. 2015 Oct. Open 12. Shannon M Bates, Ian A Greer, Saskia Middeldorp et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e691S-e736S. Open 13. Leslie Po, Jacqueline Thomas, Kelsey Mills et al. Guideline No. 414 Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies. J Obstet Gynaecol Can. 2021 May;43 5 614 630.e1. Open 14. No authors listed. Macrosomia: ACOG Practice Bulletin, Number 216. Obstet Gynecol. 2020 Jan;135 1):e18-e35. Open 15. Venu Jain, Hayley Bos, Emmanuel Bujold. Guideline No. 402 Diagnosis and Management of Placenta Previa. J Obstet Gynaecol Can. 2020 Jul;42 7 906 917.e1. Open 16. Sarah D McDonald, Michael Narvey, William Ehman et al. Guideline No. 424 Umbilical Cord Management in Preterm and Term Infants. J Obstet Gynaecol Can. 2022 Mar;44 3 313 322.e1. Open 17. Robert Gagnon. No. 231 Guidelines for the Management of Vasa Previa. J Obstet Gynaecol Can. 2017 Oct;39 10):e415-e421. Open https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 7/8 6/29/23, 3:50 AM Cesarean delivery Pathway 18. Jauniaux E, Alfirevic Z, Bhide AG et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG. 2019 Jan;126 1):e1-e48. Open 19. Royal College of Obstetricians and Gynaecologists. Shoulder Dystocia: Green top Guideline No. 42. RCOG. 1 Mar 2012. Open 20. Eman Alsayegh, Hayley Bos, Kim Campbell et al. No. 361 Caesarean Delivery on Maternal Request. J Obstet Gynaecol Can. 2018 Jul;40 7 967 971. Open 21. Marie-Jocelyne Martel, Catherine Jane MacKinnon. No. 155 Guidelines for Vaginal Birth After Previous Caesarean Birth. J Obstet Gynaecol Can. 2018 Mar;40 3):e195-e207. Open 22. No authors listed. Committee Opinion No. 725 Vaginal Seeding. Obstet Gynecol. 2017 Nov;130 5):e274-e278. Open 23. No authors listed. WHO recommendations: Intrapartum care for a positive childbirth experience. WHO. 2018. Open 24. No authors listed. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. Geneva: World Health Organization; 2015. Open 25. Christine Bloch, Sharon Dore, Sebastian Hobson. Committee Opinion No. 415 Impacted Fetal Head, Second-Stage Cesarean Delivery. J Obstet Gynaecol Can. 2021 Mar;43 3 406 413. Open 26. No authors listed. ACOG Practice Bulletin No. 211 Critical Care in Pregnancy. Obstet Gynecol. 2019 May;133 5):e303-e319. Open 27. No authors listed. Practice Bulletin No 178 Shoulder Dystocia. Obstet Gynecol. 2017 May;129 5):e123- e133. Open 28. Society of Maternal-Fetal SMFM Publications Committee, Rachel G Sinkey, Anthony O Odibo et al. #37 Diagnosis and management of vasa previa. Am J Obstet Gynecol. 2015 Nov;213 5 615 9. Open 29. Macones GA, Caughey AB, Wood SL et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery ERAS Society recommendations (part 3 . Am J Obstet Gynecol. 2019 Sep;221 3 247.e1 247.e9. Open 30. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 205 Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019 Feb;133 2):e110-e127. Open 31. Lo c Sentilhes, Marie V S nat, Ma la Le Lous et al. Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery. N Engl J Med. 2021 Apr 29;384 17 1623 1634. Open 32. Alan T N Tita, Jeff M Szychowski, Kim Boggess et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med. 2016 Sep 29;375 13 1231 41. Open 33. Royal College of Obstetricians and Gynaecologists. Blood Transfusion in Obstetrics. RCOG. 2015 May. Open https://web.pathway.md/diseases/reccBUZd3KVEzjN2M 8/8