Editing Caesarean section (section)

==Technique==
[[File:Cesareo.svg|thumb|Several caesarean sections<br />
Is: supra-umbilical incision<br />
Im: median incision<br />
IM: Maylard incision<br />
IP: Pfannenstiel incision]]
[[File:Caesarian section - Pull out.jpg|thumb|Removal of the baby]]
[[File:Blausen 0223 CesareanDelivery.png|thumb|Illustration depicting caesarean section]]

[[Antibiotic prophylaxis]] is used before an incision.<ref name="DahlkeMendez-Figueroa2013">{{cite journal | vauthors = Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP | title = Evidence-based surgery for cesarean delivery: an updated systematic review | journal = American Journal of Obstetrics and Gynecology | volume = 209 | issue = 4 | pages = 294–306 | date = October 2013 | pmid = 23467047 | doi = 10.1016/j.ajog.2013.02.043 }}</ref> The [[uterus]] is incised, and this incision is extended with blunt pressure along a cephalad-caudad axis.<ref name="DahlkeMendez-Figueroa2013"/> The infant is delivered, and the [[placenta]] is then removed.<ref name="DahlkeMendez-Figueroa2013"/> The surgeon then decides about uterine exteriorization.<ref name="DahlkeMendez-Figueroa2013"/> Single-layer uterine closure is used when the mother does not want a future pregnancy.<ref name="DahlkeMendez-Figueroa2013"/> When subcutaneous tissue is 2&nbsp;cm thick or more, [[surgical suture]] is used.<ref name="DahlkeMendez-Figueroa2013"/> Discouraged practices include manual [[cervical dilation]], any subcutaneous [[Drain (surgery)|drain]],<ref>{{cite journal | vauthors = Gates S, Anderson ER | title = Wound drainage for caesarean section | journal = The Cochrane Database of Systematic Reviews | issue = 12 | pages = CD004549 | date = December 2013 | pmid = 24338262 | doi = 10.1002/14651858.CD004549.pub3 }}</ref> or supplemental [[oxygen therapy]] with intent to prevent infection.<ref name="DahlkeMendez-Figueroa2013"/>

Caesarean section can be performed with [[single layer suturing|single]] or [[double layer suturing]] of the uterine incision.<ref name="pmid7781869">{{cite journal | vauthors = Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR | title = Evaluation of combinations of procedures in cesarean section | journal = International Journal of Gynaecology and Obstetrics | volume = 48 | issue = 3 | pages = 273–276 | date = March 1995 | pmid = 7781869 | doi = 10.1016/0020-7292(94)02306-J | s2cid = 72559269 }}</ref> Single layer closure compared with double layer closure has been observed to result in reduced blood loss during the surgery. It is uncertain whether this is the direct effect of the suturing technique or if other factors such as the type and site of abdominal incision contribute to reduced blood loss.<ref>{{cite journal | vauthors = Dodd JM, Anderson ER, Gates S, Grivell RM | title = Surgical techniques for uterine incision and uterine closure at the time of caesarean section | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD004732 | date = July 2014 | pmid = 25048608 | doi = 10.1002/14651858.CD004732.pub3 | pmc = 11182567 }}</ref> Standard procedure includes the closure of the [[peritoneum]]. Research questions whether this is needed, with some studies indicating peritoneal closure is associated with longer operative time and hospital stay.<ref>{{cite journal | vauthors = Bamigboye AA, Hofmeyr GJ | title = Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 8 | pages = CD000163 | date = August 2014 | pmid = 25110856 | pmc = 4448220 | doi = 10.1002/14651858.CD000163.pub2 }}<!--|access-date=12 May 2015--></ref> The Misgav Ladach method is a surgery technical that may have fewer secondary complications and faster healing, due to the insertion into the muscle.<ref>{{cite journal | vauthors = Holmgren G, Sjöholm L, Stark M | title = The Misgav Ladach method for cesarean section: method description | journal = Acta Obstetricia et Gynecologica Scandinavica | volume = 78 | issue = 7 | pages = 615–621 | date = August 1999 | pmid = 10422908 | doi = 10.1034/j.1600-0412.1999.780709.x | s2cid = 25845500 }}</ref>

===Anesthesia===
Both [[general anesthesia|general]] and [[regional anesthesia|regional anaesthesia]] ([[spinal anaesthesia|spinal]], [[epidural]] or [[combined spinal and epidural anaesthesia]]) are acceptable for use during caesarean section. Evidence does not show a difference between regional anaesthesia and general anaesthesia concerning major outcomes in the mother or baby.<ref name="Afolabi">{{cite journal | vauthors = Afolabi BB, Lesi FE | title = Regional versus general anaesthesia for caesarean section | journal = The Cochrane Database of Systematic Reviews | volume = 10 | pages = CD004350 | date = October 2012 | pmid = 23076903 | doi = 10.1002/14651858.CD004350.pub3 | pmc = 12009660 }}</ref> Regional anaesthesia may be preferred as it allows the mother to be awake and interact immediately with her baby.<ref name=Hawkins>{{cite journal | vauthors = Hawkins JL, Koonin LM, Palmer SK, Gibbs CP | title = Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990 | journal = Anesthesiology | volume = 86 | issue = 2 | pages = 277–284 | date = February 1997 | pmid = 9054245 | doi = 10.1097/00000542-199702000-00002 | s2cid = 21467445 | doi-access = free }}</ref> Compared to general anaesthesia, regional anaesthesia is better at preventing [[persistent postoperative pain]] 3 to 8 months after caesarean section.<ref>{{cite journal | vauthors = Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH | title = Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children | journal = The Cochrane Database of Systematic Reviews | volume = 6 | issue = 6 | pages = CD007105 | date = June 2018 | pmid = 29926477 | pmc = 6377212 | doi = 10.1002/14651858.CD007105.pub4 }}</ref> Other advantages of regional anesthesia may include the absence of typical risks of general anesthesia: [[pulmonary aspiration]] (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and [[Esophagus|esophageal]] [[intubation]].<ref name=Afolabi/> One trial found no difference in satisfaction when general anaesthesia was compared with either spinal anaesthesia.<ref name="Afolabi" />

Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled caesarean section.<ref name="Bucklin">{{cite journal | vauthors = Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA | title = Obstetric anesthesia workforce survey: twenty-year update | journal = Anesthesiology | volume = 103 | issue = 3 | pages = 645–653 | date = September 2005 | pmid = 16129992 | doi = 10.1097/00000542-200509000-00030 | doi-access = free }}</ref> Regional anaesthesia during caesarean section is different from the [[analgesia]] (pain relief) used in labor and vaginal delivery.<ref>{{cite journal | vauthors = Wang SC, Pan PT, Chiu HY, Huang CJ | title = Neuraxial magnesium sulfate improves postoperative analgesia in Cesarean section delivery women: A meta-analysis of randomized controlled trials | journal = Asian Journal of Anesthesiology | volume = 55 | issue = 3 | pages = 56–67 | date = September 2017 | pmid = 28797894 | doi = 10.1016/j.aja.2017.06.005 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Lavoie A, Toledo P | title = Multimodal postcesarean delivery analgesia | journal = Clinics in Perinatology | volume = 40 | issue = 3 | pages = 443–455 | date = September 2013 | pmid = 23972750 | doi = 10.1016/j.clp.2013.05.008 | series = Pain Management in the Peripartum Period }}</ref><ref>{{cite journal | vauthors = Nardi N, Campillo-Gimenez B, Pong S, Branchu P, Ecoffey C, Wodey E | title = [Chronic pain after cesarean: Impact and risk factors associated] | language = fr | journal = Annales Françaises d'Anesthésie et de Réanimation | volume = 32 | issue = 11 | pages = 772–778 | date = November 2013 | pmid = 24138769 | doi = 10.1016/j.annfar.2013.08.007 }}</ref> The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense [[nerve block]].

General anesthesia may be necessary because of specific risks to the mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress when there is no time to perform a regional anesthesia.

===Prevention of complications===

Postpartum infection is one of the main causes of maternal death and may account for 10% of maternal deaths globally.<ref name="Kassebaum-2014">{{cite journal | vauthors = Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al | title = Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 | journal = Lancet | volume = 384 | issue = 9947 | pages = 980–1004 | date = September 2014 | pmid = 24797575 | pmc = 4255481 | doi = 10.1016/S0140-6736(14)60696-6 }}</ref><ref name="NICE2011" /><ref name=pmid25350672>{{cite journal | vauthors = Smaill FM, Grivell RM | title = Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 10 | pages = CD007482 | date = October 2014 | pmid = 25350672 | pmc = 4007637 | doi = 10.1002/14651858.CD007482.pub3 }}</ref> A caesarean section greatly increases the risk of infection and associated morbidity, estimated to be between 5 and 20 times as high, and routine use of antibiotic prophylaxis to prevent infections was found by a [[meta-analysis]] to substantially reduce the incidence of febrile morbidity.<ref name=pmid25350672/> Infection can occur in around 8% of women who have caesareans,<ref name=NICE2011 /> largely [[endometritis]], [[urinary tract infections]] and wound infections. Preventative antibiotics in women undergoing caesarean section decreased wound infection, endometritis, and serious infectious complications by about 65%.<ref name=pmid25350672/> Side effects and effects on the baby are unclear.<ref name=pmid25350672/>

Women who have caesareans can recognize the signs of fever that indicate the possibility of wound infection.<ref name=NICE2011 /> Taking antibiotics before skin incision rather than after [[cord clamping]] reduces the risk for the mother, without increasing adverse effects for the baby.<ref name=NICE2011 /><ref name="MackeenPackard2014">{{cite journal | vauthors = Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK | title = Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery | journal = The Cochrane Database of Systematic Reviews | issue = 12 | pages = CD009516 | date = December 2014 | pmid = 25479008 | doi = 10.1002/14651858.CD009516.pub2 | doi-access =  | pmc = 11227345 }}</ref> Moderate certainty evidence suggests that [[Chlorhexidine Gluconate|chlorhexidine gluconate]] as a skin preparation is slightly more effective in the prevention of surgical site infections than [[povidone-iodine]] but further research is needed.<ref>{{cite journal | vauthors = Hadiati DR, Hakimi M, Nurdiati DS, Masuzawa Y, da Silva Lopes K, Ota E | title = Skin preparation for preventing infection following caesarean section | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 6 | pages = CD007462 | date = June 2020 | pmid = 32580252 | pmc = 7386833 | doi = 10.1002/14651858.CD007462.pub5 }}</ref>

Some doctors believe that during a caesarean section, mechanical [[cervical dilation]] with a finger or forceps will prevent the obstruction of blood and [[lochia]] drainage, and thereby benefit the mother by reducing the risk of death. The evidence {{As of|2018|lc=y}} neither supported nor refuted this practice for reducing postoperative morbidity, pending further large studies.<ref>{{cite journal | vauthors = Liabsuetrakul T, Peeyananjarassri K | title = Mechanical dilatation of the cervix during elective caeserean section before the onset of labour for reducing postoperative morbidity | journal = The Cochrane Database of Systematic Reviews | volume = 8 | issue = 8 | pages = CD008019 | date = August 2018 | pmid = 30096215 | pmc = 6513223 | doi = 10.1002/14651858.CD008019.pub3 }}</ref>

[[Hypotension]] (low blood pressure) is common in women who have spinal anaesthesia; intravenous fluids such as [[crystalloids]], or compressing the legs with bandages, stockings, or inflatable devices may help to reduce the risk of hypotension but the evidence is still uncertain about their effectiveness.<ref>{{cite journal | vauthors = Chooi C, Cox JJ, Lumb RS, Middleton P, Chemali M, Emmett RS, Simmons SW, Cyna AM | title = Techniques for preventing hypotension during spinal anaesthesia for caesarean section | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 7 | pages = CD002251 | date = July 2020 | pmid = 32619039 | pmc = 7387232 | doi = 10.1002/14651858.CD002251.pub4 }}</ref>

===Skin-to-skin contact===

The [[WHO]] and [[UNICEF]] recommend that infants born by Caesarean section should have skin-to-skin contact (SSC) as soon as the mother is alert and responsive.  Immediate SSC following a spinal or epidural anesthetic is possible because the mother remains alert; however, after a general anaesthetic, the father or other family member may provide SSC until the mother is able.<ref name="Immediate or early skin-to-skin con">{{cite journal | vauthors = Stevens J, Schmied V, Burns E, Dahlen H | title = Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature | journal = Maternal & Child Nutrition | volume = 10 | issue = 4 | pages = 456–473 | date = October 2014 | pmid = 24720501 | pmc = 6860199 | doi = 10.1111/mcn.12128 }}</ref>

It is known that during the hours of labor before a vaginal birth, a woman's body begins to produce [[oxytocin]] which aids in the bonding process, and it is thought that SSC can trigger its production as well.  Indeed, women have reported that they felt that SSC had helped them to feel close to and bond with their infant.  A review of literature also found that immediate or early SSC increased the likelihood of successful breastfeeding and that newborns were found to cry less and relax quicker when they had SSC with their father as well.<ref name="Immediate or early skin-to-skin con"/>