Caesarean section: how it is performed

A cesarean section is a surgical procedure performed through an incision in the abdominal wall and uterus. Over the past decades, the frequency of cesarean sections has increased in many countries, necessitating a reassessment of approaches: the procedure saves lives when medically indicated, but when unjustifiably expanded, it increases risks for mother and child. The World Health Organization emphasizes that there is no "ideal" cesarean section rate: the goal of the system is to ensure that the procedure is performed for those who truly need it, not to achieve a set percentage. [1]

Current practice is based on clinical guidelines and protocols for "enhanced postoperative recovery" for cesarean section. These protocols integrate preoperative, intraoperative, and postoperative measures, reducing complications and length of hospital stay, and improving patient satisfaction. Updates for the prenatal, intraoperative, and postoperative stages are regularly published by specialized societies and demonstrate a consistent reduction in complications when properly implemented. [2]

A key organizational principle is shared decision-making: indications, risks, and alternatives are discussed in advance, and individual risk factors, preferences, and resource availability are assessed. Timing is a key consideration: for planned deliveries without additional reasons for early delivery, the procedure is recommended no earlier than 39 weeks to reduce the incidence of respiratory distress in newborns. [3]

Finally, sustainable quality is achieved not by a single measure, but by a combination of interventions: rational anesthesia, prevention of infection, bleeding, and thromboembolism, gentle surgical techniques, and early mobilization. This “package” of solutions creates a predictable and safe patient journey from the operating room to discharge. [4]

Indications and planning of surgery

Indications for cesarean section are divided into maternal and fetal. Maternal indications include placenta previa and a range of abnormal placental attachments, impending uterine rupture, severe preeclampsia with unprepared birth canal, and prior uterine surgery with a high risk of rupture. Fetal block indications include abnormal fetal position and presentation, significant signs of fetal distress based on observation, multiple pregnancies in certain configurations, and certain congenital conditions for which surgical removal is safer. [5]

Planning includes an assessment of the general condition, correction of associated risk factors, discussion of pain management, and routing in case of intraoperative complications. A clear plan for antibiotic prophylaxis and blood loss management is essential, as is information about postoperative recovery and breastfeeding. "Enhanced recovery" programs recommend standardized preoperative preparation checklists. [6]

A planned cesarean section without additional medical reasons should not be performed before 39 weeks. Earlier cesarean delivery increases the risk of respiratory distress, transient tachypnea, and the need for intensive care in the newborn, so it is performed only for medical reasons. [7]

If a woman has had a cesarean section, two options are discussed for a subsequent pregnancy: a repeat cesarean section or an attempt at vaginal delivery after a previous cesarean section. The choice depends on the type of previous uterine incision, the number of previous surgeries, the obstetric situation, and the facility's readiness for emergency care. Guidelines emphasize the need for an individualized, informed decision. [8]

Table 1. Main indications for cesarean section

Group	Examples of situations
Maternal	Placenta previa, a spectrum of pathological placental attachment, severe hypertension with unpreparedness for labor, aggravated uterine scars
Fruit	Incorrect positions and presentations, pronounced signs of fetal distress, some developmental anomalies
Combined	Fetal-pelvic size discrepancy, ineffective or impossible labor management, a combination of several risk factors

Source: Guidelines for cesarean section and delivery timing. [9]

Urgency Classification: Why is it Necessary?

To ensure reliable team communication, a four-category urgency classification, proposed and validated in clinical practice, is used. Category 1: immediate threat to the life of the mother or child; Category 2: significant but not immediate deterioration in condition; Category 3: the need for delivery without signs of compromise; Category 4: elective surgery. This scale helps to correctly prioritize and allocate resources. [10]

The classification serves not as a formal reporting tool, but rather as a practical coordination tool: the anesthesiology service, neonatologists, and the surgical team work synchronously based on the category. This reduces delays, lowers the risk of communication errors, and allows for more accurate assessment of decision-rescue intervals, especially in emergency situations. [11]

It is important to remember that urgency is a continuum, and even within a single category, cases may differ in the pace of decision-making. Guidelines recommend using categories for all operative deliveries and regularly auditing the appropriateness of routing to the clinical situation. [12]

Local regulations often supplement the classification with example indications for each category, which increases consistency in interpretation and reduces gray areas. This is particularly useful in institutions with a high volume of emergency patients. [13]

Table 2. Classification of caesarean section urgency

Category	Clinical essence	Examples
1	Immediate threat to the life of the mother or fetus	Suspected uterine rupture, massive bleeding, umbilical cord prolapse
2	Serious, but not immediate, compromise	Severe fetal hypoxia, cessation of labor progression due to suffering
3	There are no signs of compromise, but early delivery is required.	Severe hypertension without critical condition, premature rupture of membranes with unfavorable conditions
4	Planned surgery	Obstetric plan in a stable condition

Source: Clinical guidelines for classification of urgency.[14]

Pain relief and anesthesia: a modern standard

Neuraxial anesthesia is considered the preferred method for cesarean section because it provides good pain relief, minimizes airway management risks, and allows for early maternal-fetal contact. According to major professional societies, the vast majority of elective surgeries are performed this way, with general anesthesia reserved for specific clinical scenarios. [15]

A key intraoperative problem during spinal anesthesia is arterial hypotension. An international consensus statement recommends prophylactic infusions of vasopressors, primarily phenylephrine, in combination with a "colada" of crystalloids, which reduces nausea and vomiting and improves uteroplacental perfusion. Recent reviews confirm the benefit of a proactive strategy. [16]

Within the framework of "enhanced recovery" programs, the anesthesia section includes multimodal pain and nausea prevention, rational use of opioids, and clear monitoring criteria after the administration of neuraxial opioids. This accelerates recovery, facilitates early arousal, and facilitates breastfeeding. [17]

If neuraxial technique is not feasible, general anesthesia is administered taking into account obstetric factors, including the increased risk of difficult intubation, rapid desaturation, and regurgitation. The strategy includes preparation for a difficult airway and close collaboration with the obstetric team to minimize delays in fetal delivery. [18]

Table 3. Anesthesia for cesarean section: what is important

Element	Practice
Selecting a method	Neuraxial technique as standard, general anesthesia - according to indications
Prevention of hypotension	Prophylactic vasopressor and crystalloid "colode"
Prevention of nausea	Combination of non-drug and drug measures
Postoperative control	Rational monitoring of neuraxial opioids and multimodal analgesia

Sources: professional guidelines and consensus statements. [19]

Infection prevention: antiseptics and antibiotics

Antibiotic prophylaxis is administered before skin incision. The standard drug remains a first-generation cephalosporin at a weight-adjusted dose. For intraoperative or "uncoordinated" situations, when surgery is performed during labor or after amniotic fluid rupture, the addition of azithromycin to the standard regimen reduces the incidence of endometritis and wound infection, according to a randomized trial. [20]

Preoperative skin preparation is performed using modern antiseptics according to local protocols, taking into account skin sensitivity and operating room conditions. Additional measures include reducing the time from antiseptic application to incision, rational hair management, and limiting equipment contact with the surgical site. These simple steps reduce the incidence of postoperative infections. [21]

Vaginal antisepsis in patients with prolonged anhydrous intervals or severe colonization may be discussed in local protocols; however, timely antibiotic administration and strict surgical discipline remain essential. Repeat doses of antibiotics are indicated for prolonged surgery or massive blood loss. [22]

Within the framework of “enhanced recovery” programs, infection prevention is combined with early mobilization, glycemic control and nutritional optimization, which comprehensively reduces the risk of wound complications and accelerates healing. [23]

Table 4. Antibiotic prophylaxis during cesarean section

Scenario	Scheme
Planned surgery	Administration of a first-generation cephalosporin before skin incision, dose based on body weight
Surgery during childbirth or after the waters have broken	Addition of azithromycin to the standard regimen before skin incision
Long surgery or massive blood loss	Repeat dose according to the institution's protocol

Source: Clinical practice guidelines and randomized trial of azithromycin addition.[24]

Management of blood loss: uterotonics and the role of tranexamic acid

The standard for preventing postpartum hemorrhage after cesarean section is the timely administration of uterotonics. Oxytocin is recommended as a first-line agent, and in some healthcare systems, carbetocin may be substituted under certain conditions. The choice of agent is determined by availability, stability, and safety profile. [25]

Tranexamic acid has a well-established place in the treatment of established postpartum hemorrhage when administered early. Prophylactic use during cesarean section has been extensively studied: a large modern study failed to demonstrate a reduction in the combined outcome of death or transfusion with routine prophylactic administration, limiting its widespread prophylactic use without individual indications. [26]

A comprehensive strategy also includes measuring and documenting blood loss, preparedness for escalating therapy, and clear protocols for massive transfusion. Standardized measures reduce the likelihood of late recognition of bleeding and improve outcomes. [27]

Team training with regular simulations, availability of uterotonics and antifibrinolytics, and interdisciplinary guidelines are the basis for a consistently low rate of severe bleeding and hysterectomies for life-saving indications. [28]

Table 5. Prevention and treatment of postpartum hemorrhage after cesarean section

Direction	Practice
Prophylaxis with uterotonics	Oxytocin as a standard immediately after fetal delivery
Antifibrinolytics	Tranexamic acid - for treatment of bleeding when administered early; routine use for prophylaxis is limited by data
Measuring blood loss	Standardized assessment and documentation
Escalation	Massive transfusion protocol, team regulations

Sources: guidelines and current efficacy data. [29]

Surgical Technique: What Research Supports

Various access and technique options exist. Joel-Cohen-based techniques and their modifications have been shown to have advantages in terms of operative time and postoperative outcomes compared with classical approaches in systematic reviews, although the impact on serious long-term outcomes is limited by the quality of the evidence. The choice of technique should take into account the experience of the team and the obstetric situation. [30]

The method of uterine incision expansion—blunt or sharp—has not demonstrated a convincing difference in the incidence of infectious complications; preference is determined by convenience and control of blood loss in a particular situation. Peritoneal closure has not demonstrated a clear advantage in terms of pain and adhesion formation in most studies, so either skipping the incision or suturing it is acceptable for clinical indications. [31]

Uterine incision closure is performed in one or two layers; when planning future pregnancies, many surgeons favor a two-layer technique, although the evidence base is mixed and requires consideration of individual factors. External repositioning of the uterus for closure versus in situ closure is assessed based on the team's experience, taking into account tolerability and hemodynamics. [32]

Finally, skin closure with suturing is often associated with fewer wound complications compared to staples in a number of studies; the choice of skin material and technique is tailored to the wound phenotype and risk of infection. Regardless of the choice, atraumaticity, hemostasis, and strict adherence to protocols remain the foundation of success. [33]

Table 6. Elements of surgical technique and their evidence base

Element	Brief conclusion
Joel-Cohen Access and Modifications	May reduce time and improve early outcomes
Expansion of the uterine incision	Comparable infectious outcomes in blunt and acute variants
Peritoneum	It is permissible not to suture in the absence of special reasons
Uterine suturing	One or two layers - the choice depends on reproductive plans and the situation
Skin closure	Stitching often causes fewer wound problems than staples.

Sources: Systematic reviews and technique guidelines. [34]

Prevention of thromboembolism

Pregnancy and the early postpartum period increase the risk of venous thromboembolism, and surgery further increases this risk. Standardized assessment scales and risk stratification are recommended for all patients before and after surgery. Based on the assessment, mechanical prophylaxis is prescribed and, if risk factors are present, drug prophylaxis with low-molecular-weight heparins is prescribed for the recommended duration. [35]

Specialized societies recommend specific timeframes: approximately 10 days for moderate risk and up to 6 weeks after birth for high risk. Individualization, taking into account body weight, bleeding, and associated conditions, is important, as is interdisciplinary discussion of controversial cases. [36]

Having a local protocol with a clear scale and checklist makes prophylaxis prescription predictable, reduces variability, and improves adherence. Regular auditing of prescriptions after cesarean section helps maintain a low rate of thromboembolic events. [37]

Mechanical measures—early mobilization, compression stockings, intermittent pneumatic compression—are mandatory for all patients unless contraindicated. They complement, but do not replace, pharmacological prophylaxis in individuals at increased risk. [38]

Table 7. Prevention of venous thromboembolism after cesarean section

Risk	Measures
Base	Early mobilization, compression stockings, risk assessment
Moderate	Addition of low molecular weight heparin for approximately 10 days
High	Low molecular weight heparin for up to 6 weeks, monitoring of bleeding factors

Sources: national and international guidelines. [39]

Newborn and early postnatal period

Delayed cord clamping for 30-60 seconds is also recommended for cesarean sections, unless contraindicated, as it improves circulating blood volume and iron status in the fetus. Early skin-to-skin contact and early initiation of breastfeeding in the operating room are also encouraged, provided the mother and baby are stable. [40]

"Enhanced recovery" programs support minimal fluid load, early feeding, early mobilization, rational pain management, and a clear strategy for removing catheters and drains. Together, these programs accelerate recovery, reduce nausea, improve pain control, and increase the rate of successful breastfeeding by discharge. [41]

Reliable nausea prophylaxis and multimodal analgesia, including nonsteroidal anti-inflammatory drugs and paracetamol, reduce the need for opioids and the associated drowsiness and nausea. This facilitates child care and early arousal. [42]

Discharge criteria should be clear: stable vital signs, controlled pain on oral medication, ability to walk and care for the child independently, a monitoring plan in place and, if necessary, thromboprophylaxis at home. [43]

Table 8. Key elements of early recovery after cesarean section

Stage	Element
Immediately after extraction	Delayed cord clamping, skin-to-skin contact
The first hours	Early feeding, multimodal analgesia, nausea prevention
The first day	Early mobilization, wound assessment, lactation plan
Before discharge	Education, follow-up plan, and, if necessary, extended thromboprophylaxis

Sources: "Advanced Recovery" software updates. [44]

Long-term consequences and future pregnancies

Following a cesarean section, risks in subsequent pregnancies increase, including placenta previa and a range of pathological placental attachments. If such pathologies are suspected, referral to specialized centers with multidisciplinary teams, where blood, an experienced team, and established protocols are available, is recommended. This reduces mortality and the incidence of major bleeding. [45]

The choice of delivery method for the next pregnancy is made on an individual basis: the patient's history of uterine incisions, the number of previous surgeries, the interval between births, the fetal weight, and the facility's readiness for emergency intervention are assessed. Guidelines insist on full information about the risks of attempting a vaginal delivery after a previous cesarean section and the risks of a repeat surgery. [46]

At the population level, the management goal is not to reduce the proportion of surgeries at any cost, but to ensure timely and appropriate access to safe operative delivery, minimizing unnecessary interventions. This is consistent with the positions of international organizations, which emphasize the absence of a "target percentage" and the need for clinical validity. [47]

Continuous quality improvement includes auditing indications, outcomes, and protocol adherence, team training, and the implementation of simulations and feedback. This approach has been shown to reduce practice variability and improve safety for mother and child. [48]

Table 9. Spectrum of pathological placental attachment: organization of care

Paragraph	Recommended approach
Identification	Early screening and preoperative imaging for risk factors
Routing	Referral to a center with a multidisciplinary team
Operation plan	Preparedness for massive blood loss, blood products, experienced team
Tactics	Most often, a cesarean hysterectomy is performed with the placenta left in place.

Sources: consensus documents and reviews. [49]