COVER PAGE

Philippine Obstetrical and

Gynecological Society (POGS), Foundation, Inc.

CLINICAL PRACTICE GUIDELINES

on
CESAREAN SECTION
Second Edition, November 2009

November 2009

Task Force on Clinical Practice Guideline

In the Management of Cesarean Section
 Philippine Obstetrical and
Gynecological Society (POGS),
Foundation, Inc

CLINICAL PRACTICE GUIDELINES

on
CESAREAN SECTION

November 2009
 FOREWORD

Insert Picture of
Dr. Capito

LOURDES B. CAPITO, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009

I have envisioned and have implemented to completion the publication of a series of

Clinical Practice Guidelines on the major procedures and topics of Obstetrics and Gynecology.
This is in consonance with the theme of my Presidency, Babae, Kalusugan Mo, Katungkulan
Natin. This is the Clinical Practice Guidelines on Cesarean Section and is the First Edition of
this Publication, 2009.

In the role of the POGS to provide its members with updates, current and standard
practice recommendations and guidelines, this publication will fulfill the objective of continuing
education and implementation of refinements in Obstetrics and Gynecology. In keeping with the
highest standards of care, the Level and Grades of Clinical Practice/Recommendation has been
adopted for every recommendation that is completed and decided.

In the process of the formulation of the guideline/recommendation, the entire

membership of the POGS was consulted. I take special effort to thank the AdHoc Committee on
Clinical Practice Guidelines, headed by its Chair, Dr. Efren J. Domingo for the unceasing tireless
effort to complete this publication. I also gratefully acknowledge the Chairs and Training Officers
of the Residency-Accredited Hospitals, the Task Force Reviewers, and the CME Committee.

It becomes easy, dignified and scientific to conduct the practice of Obstetrics and
Gynecology specifically on Cesarean Section. Now, the Clinical Practice Guidelines on Cesarean
Section will hope to update and make the practice current and responsive to world-class standards
and make the patients under our care deserving of the trust and confidence that we, Obstetricians,
impart with utmost care and compassion.

LOURDES BLANCO-CAPITO, MD
 INTRODUCTION

Efren J. DOMINGO, MD, PhD.

Chair, AdHoc Committee on the Clinical Practice Guidelines, 2009

The Clinical Practice Guidelines on Cesarean Section is the First Edition of this
Publication, 2009. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc.
(POGS), through the AdHoc Committee on Clinical Practice Guidelines initiated and led to
completion the publication of this manual in plenary consultation with the Residency Accredited
Training Hospitals Chairs and Training Officers, The Regional Board of Directors, The Board of
Trustees, The Task Force Reviewers for Cesarean Section and the Committee on Continuing
Medical Education.

This publication represents the collective effort of the POGS in updating the clinical
practice of Obstetrics and Gynecology, specifically on Cesarean Section, and making it
responsive to the most current and acceptable standard in this procedure. A greater part of the
inputs incorporated in this edition are the contributions originating from the day-to-day academic
interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and
Gynecology in the country.

This Clinical Practice Guideline on Cesarean Section is envisioned to become the handy
companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality care and
decision making in managing the Obstetric patient. This is also envisioned to provide the
academic institutions in the country and in Southeast Asia updated information and Cesarean
Section procedure refinements being practiced in the Philippines.

Profound gratitude is extended to all the members of the POGS, the Chairs and Training
Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Task
Force On Cesarean Section Reviewers/Contributors, The CME Committee members, and the
2009 POGS Board of Trustees.

EFREN J. DOMINGO, MD, PhD

BOARD OF TRUSTEES 2009

OFFICERS

Lourdes B. Capito, MD
President

Regta L. Pichay, MD
Vice President

Ma. Carmen H. Quevedo, MD

Secretary

Ditas Christina D. Decena, MD

Treasurer

Christia S. Padolina, MD
Public Relations Officer

BOARD OF TRUSTEES
Mayumi S. Bismarck, MD
Virgilio B. Castro, MD
Efren J. Domingo, MD, PhD
Gil S. Gonzales, MD
Diosdado V. Mariano, MD
Ma. Socorro M. Solis, MD
 ADHOC COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON CESAREAN SECTION

Efren J. Domingo, MD, PhD

Chair

MEMBERS
Jennifer T. Co, MD
Jericho Thaddeus P. Luna, MD
Josephine M. Lumitao, MD
Lisa Teresa P. Jabson, MD
Noel E. Raymundo, MD
Elisa O. Tiu, MD

FELLOWS
Rachelle U. delos Reyes, MD Ana Victoria V. Dy Echo, MD
May Nueva-Hipolito, MD Michelle R. Ong, MD
Renee Vina G. Sicam, MD

TECHNICAL STAFF ASSISTANTS

Ms. Emiliana C. Enriquez
Ma. Jhasmin G. De Guzman

TASK FORCE FOR CESAREAN SECTION

Mario R. Festin, MD, MHPEd Lora G. Tansengco, MD Guadalupe N. Villanueva, MD

Milagros T. Jocson, MD Cristina P. Crisologo, MD Valerie Tiempo-Guinto, MD
Ma. Antonia E. Habana, MD Regina P. Vitriolo, MD Concepcion Cruz, MD
Grace Herbosa, MD Esmeraldo Ilem, MD Ana Hamada, MD
Ramon M. Gonzalez, MD

TASK FORCE REVIEWERS AND PLENARY REVIEWERS

Rainerio S. Abad, MD Arcangel N. Diamante, MD Patria P. Punsalan, MD

Imelda O. Andres, MD
Cecilia Joyce M. Bascarra, MD
Mayumi S. Bismark, MD
Ricardo R. Braganza, MD
Sylvia A. Carnero, MD
Virgilio B. Castro, MD
Lyra Ruth Clemente-Chua, MD
Maria Lourdes B. Coloma, MD
Godofreda V. Dalmacion, MD
Ditas Cristina D. Decena, M.D
Santiago A. del Rosario, MD
Rey H. Delos Reyes, MD
Virginia R. de Jesus, MD
Rommel Z. Dueas, MD
Joseline A. Ferrolino, MD
Ma. Corazon N. Gamilla, MD
Erlinda G. Germar, MD
Myrna R. Habaa, MD
Bernardita B. Javier, MD
Lilia P. Luna, MD
Augusto M. Manalo, MD
Diosdado V. Mariano, MD
Jocelyn Z. Mariano, MD
Christia S. Padolina, MD
Mildred N. Pareja, MD
Wilhelmina Pineda, MD
Ma. Carmen H. Quevedo, MD
Rebecca M. Ramos, MD
Cristina C. Raymundo, MD
Rosendo R. Roque, MD
Marilyn D. Ruaro, MD
Ma. Socorro M. Solis, MD
Sherri Ann L. Suplido, MD
Walfrido W. Sumpaico, MD
Carmencita B. Tongco, MD
Ma. Victoria Torres, MD
Milagros P. Torres, MD
Ma. Trinidad R. Vera, MD

Regional Directors
Ellen A. Manzano, MD (Region 1)
Melchor C. dela Cruz, MD (Region 2)
Concepcion P. Aronza, MD (Region 3)
Ernesto S. Naval, MD (Region 4)
Rowena M. Auxillos, MD (Region 4A)
Cecilia Valdes-Neptuno, MD (Region 5)
Evelyn R. Lacson, MD (Region 6)
Belinda N. Paares, MD (Region 7)
Realino G. Molina, MD (Region 8)
Suzette S. Montuno, MD (Region 9)
Jana Joy R. Tusalem, MD (Region 10)
Amelia A. Vega, MD (Region 11)
.
 CPG ON CESAREAN SECTION
TOPICS / CONTENTS

Part I:
Indications for Cesarean Section
Breech Presentation .. 1
Multiple Pregnancy ..
Premature Rupture of Membranes ..
Placenta Previa ..
Intrauterine Growth Restriction ..
Abnormal Fetal Heart Rate Pattern ..
Optimal Decision to Delivery Interval ..
Infections in Pregnancy
Hepatitis B Infection ..
Herpes Simplex Virus ..
Human Immunodeficiency ..
Maternal Request for Cesarean Section ..

Part II:
Prenatal Provision of Information Regarding Cesarean Section ..
Optimal Time of Planned Cesarean Section ..
Routine Laboratory Tests for Cesarean Section ..
Prophylactic Antibiotics ..
Shaving ..
Abdominal Incision ..
Removal of Placenta During Cesarean Section ..
Closure of Peritoneum During Cesarean Section ..
Closure of Subcutaneous Tissue During Cesarean Section ..
Use of Indwelling Foley Catheter in Cesarean Section ..
Pediatric Attendance at Cesarean Section ..
Early Skin to Skin Contact and Breastfeeding after Cesarean Section ..
Feeding After Cesarean Section ..
Wound Care/Gauze and Transparent Polyurethane Dressings (Tegaderm)
for Cesarean Section ..
Length of Hospital Stay ..
Sexual Intercourse After Cesarean Section ;.
 BREECH AS INDICATION FOR CESAREAN SECTION

A. Recommendations

External cephalic version (ECV) may be offered to women with uncomplicated

breech presentation in the 36th week age of gestation.1,2,4 (Level I, Grade A)
o Contraindications to version would be women who are already in labor or
complicated by a previous uterine scar, abnormal fetal heart rate pattern or
fetal compromise, ruptured membranes, vaginal bleeding or other medical
conditions.3 (Level I, Grade A)

If the ECV has failed or is contraindicated, cesarean section (CS) is recommended

in term, singleton breech presentations since it decreases perinatal mortality and
neonatal morbidity. CS is also the preferred mode of delivery because of the
diminishing expertise in vaginal breech delivery. 5-10 (Level I, Grade A)

Planned vaginal delivery may be reasonable under hospital-specific protocol for

eligibility and labor management. The patients should, however, be informed that
the risk of perinatal or neonatal mortality or serious neonatal morbidity may be
higher than if a cesarean delivery was planned.5-8 (Level III, Grade B)

B. Supporting Evidence

1. External Cephalic Version

A systematic review by Hofmeyr, et. al. showed that ECV at term reduced the
number of nonvertex births compared to no ECV (5 randomized control trials (RCT),
n=433, RR 0.38, 95% CI 0.18-0.80). It also showed that ECV reduced the number of CS
compared to no ECV (5 RCT, n=433, RR 0.55, 95% CI 0.33-0.91).1 One study compared
ECV initiated at 34-35 weeks compared to term. There is still a reduction of non-vertex
births by 9.5% and CS by 7%. However, the result was not statistically significant.2
Some of the complications and incidences attributable to ECV include the
following: fetal heart rate abnormalities the most common is transient bradycardia
(1.1% to 16%), placental abruption (0.4% to 1%), painless vaginal bleeding (1.1%),
admission for induction of labor (3%).3 A systematic review of adverse outcomes of ECV
and persistent breech at term from studies of women who had ECV starting 36 weeks and
a control group of women without ECV (11 studies, n=2503) showed that there was no
increased risk of antepartum fetal death, but the numbers were small. There was no
uterine rupture, abruptio placenta, prelabor rupture of membranes, or cord prolapse.
However, these outcomes were not examined among controls. The incidence of labor
within 24 hours was not significantly higher among those who underwent ECV compared
to those who had persistent breech.4
2. Term, breech

A systematic review evaluated the effects of planned cesarean delivery for

singleton, breech presentation at term on pregnancy outcome measures.5 This included 3
RCT (n=2396). Majority of the information, however, was taken from an RCT of good
methodologic quality, which is an international collaboration performed at 121 centers in
26 countries (n=2088). CS was performed on 45% (550/1227) of women allocated to the
vaginal delivery protocol. CS was shown to decrease perinatal or neonatal death
(excluding fatal congenital anomalies) or serious neonatal morbidity (RR 0.33, 95% CI
0.19-0.56). However, compared to countries with low national perinatal mortality rates,
the reduction in risk of perinatal or neonatal death or serious neonatal morbidity was less
among nations with high national perinatal mortality rates. A planned cesarean delivery,
on the other hand, also reduced perinatal or neonatal death (excluding fatal congenital
anomalies) (RR 0.29, 95% CI 0.10-0.86). The proportional reductions were similar for
countries with low and high national perinatal mortality rates.
The systematic review and the large RCT by Hannah, et. al. have been the
subject of continuing debate.6 Result of this RCT showed that 90.4% of women assigned
to the planned CS group were actually delivered by CS, while 56.7% of those within the
planned vaginal birth group delivered vaginally. The overall risk of perinatal/neonatal
mortality or serious morbidity was 1.6% in the planned CS group and 5% in the planned
vaginal birth group (RR 0.33, 95% CI 0.19-0.56). Since the absolute risk reduction in
perinatal/neonatal mortality or serious neonatal morbidity is 3.4%, the calculated number
needed to treat (NNT) is 29. Therefore for every 29 CS for the term, breech pregnancy,
one baby will avoid death or serious morbidity. These findings are consistent with cohort
studies.7,8 Within this RCT, a subgroup analysis showed that the effect on perinatal
mortality or morbidity remains consistent and could not be explained by differences in
the following: experience of the clinician, duration of labor, induction of labor with
oxytocin or prostaglandins, augmentation of labor, type of breech presentation, or the use
of epidural anesthesia.
The systematic review showed that there was a slightly increased risk of short-
term maternal morbidity with planned CS (RR 1.29, 95% CI 1.03-1.61). No difference is
detected in the measures of maternal morbidity (such as blood loss, blood transfusion,
infection) between planned CS and planned vaginal birth. Data from the systematic
review cannot be generalized in maternal settings different from the clinical protocols of
the trials included. Therefore, the recommendation does not apply in home birth settings,
areas where CS is not readily available, and in preterm breech deliveries.

3. Preterm, breech

The results of the systematic review and the term breech trial cannot be
extrapolated to preterm breech deliveries.
An observational study showed that survival rates were lower for babies born
breech (84.5%) compared to babies born in cephalic presentation (89.4%). However, the
survival for preterm fetuses in breech presentation was significantly greater in those
delivered by CS (86.5%) than those delivered vaginally (77.4%).9
A multicenter RCT was attempted in 26 hospitals in the UK comparing elective
versus selective CS for the delivery of the preterm breech infant between 26-32 weeks.
However, no conclusions were drawn because the trial was terminated after 17 months
due to low recruitment and no formal statistical analysis was done.10
C. References

1. Hofmeyr GJ, Kulier R. External cephalic version facilitation for breech presentation at
term. Cochrane Database Syst Rev 2009; Issue 2.
2. Hutton EK, Hofmeyr GJ. External cephalic version for breech presentation before term.
Cochrane Database Syst Rev 2009; Issue 2.
3. Royal College of Obstetricians and Gynaecologists. Cesarean Section. London: RCOG
Press 2004.
4. Nassar N, Roberts CL, Barratt A, Bell JC, Olive EC, Peat B. Systematic review of
adverse outcomes of external cephalic version and persisting breech presentation at term.
Paediatr Perinat Epidemiol 2006; 20(2):163-171.
5. Hofmeyr GJ, Hannah ME. Planned cesarean section for term breech delivery. Cochrane
Database Syst Rev 2009; Issue 2.
6. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, et. al. Planned caesarean
section versus planned vaginal birth for breech presentation at term: a randomised
multicentre trial. Lancet 2000;356:13751383.
7. Herbst A, Thorngren-Jerneck K. Mode of delivery in breech presentation at term:
Increased neonatal morbidity with vaginal delivery. Acta Obstet Gynecol Scand
2001;80:731737.
8. Rietberg CC, Elferink-Stinkens PM, Brand R, van Loon AJ, Van Hemel OJ, Visser GH.
Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity
in relation to the mode of delivery of 33824 infants. Int J Gynaecol Obstet
2003;110:604609.
9. Confidential Enquiry into Stillbirths and Deaths in Infancy. An enquiry into the quality of
care and its effect on the survival of babies born at 27-28 weeks. Project 27/28. London:
TSO; 2003.
10. Penn ZJ, Steer PJ, Grant A. A multicentre randomised controlled trial comparing elective
and selective caesarean section for the delivery of the preterm breech infant. Br J Obstet
Gynaecol 1996;103(7):684-689.
 MULTIPLE PREGNANCY AS INDICATION FOR CESAREAN SECTION

A. Recommendations

In an otherwise uncomplicated term twin pregnancy where the presentation of the

first twin is cephalic, cesarean section (CS) should not be routinely offered.1
(Level III, Grade B)

In a twin pregnancy where the first of twin is not cephalic, a planned CS should
be offered.1 (Level I, Grade A)

Planned CS of uncomplicated twin pregnancies should be carried out at 38 weeks

and no later than 39 weeks.4 (Level II-2, Grade B)

For complicated twin pregnancies, planned CS should be carried out at 36 or 37

weeks or earlier, if necessary.
o In pregnancies complicated by gestational diabetes, pregestational diabetes, or
poor dating an amniocentesis for fetal lung maturity should be performed
prior to undertaking any elective delivery prior to 36 weeks. (Level III, Grade
B)

B. Supporting Evidence

1. Mode of Delivery

The American College of Obstetricians and Gynecologists (ACOG) states that

vaginal birth is anticipated for vertex-vertex twin gestations unless there are specific
contraindications to vaginal birth.
The best approach to the delivery of vertex-nonvertex twins is very controversial.
According to ACOG, vaginal birth is reasonable if infants weigh more than 1500 g and
the criteria for vaginal breech delivery are met, but the evidence is insufficient to
advocate a specific route of delivery for infants weighing less than 1500 g. In the
systematic review by Hogle, et. al., for vertex-nonvertex twins, no significant difference
in the incidence of a low 5-minute Apgar score between the planned cesarean and
planned vaginal birth groups was noted (OR 1.99; 95% CI 0.37-10.82).1
When the first of twin is breech, ACOG recommends CS because the safety of
vaginal birth has not been documented and because the possibility of locked twins exists
when twin A is nonvertex and twin B is vertex. Hogle, et. al. support this
recommendation and suggest that a policy of planned CS may result in a reduced
incidence of a low 5-minute APGAR score when twin A is breech (OR 0.33, 95% CI
0.17-0.65).1
There are reasons to believe that planned CS might be better for twin babies,
even in the vertex-nonvertex or vertex-vertex positions, if delivery is planned or
imminent or the pregnancy is at or near term. These twin pregnancies may develop
complications during labor or during an attempt at vaginal delivery. For twins weighing
 at least 1500 g or reaching at least 32 weeks of gestation, delivered vaginally or by CS
during labor, rates of adverse perinatal outcome have been reported to be high. Perinatal
or neonatal mortality rates have varied from 0% to 6.2%, rates of low 5-minute Apgar
score from 0% to 7.4%, and rates of birth trauma from 0% to 2.1%.1 Reported rates of
birth asphyxia are from 3.9% to 6.2%; 1.4% had cerebral palsy or mental retardation at 8
years or more.1 A policy of planned CS, by avoiding labor and vaginal delivery, might
reduce the risk of some of these complications. However, a policy of planned CS for twin
infants might increase the risk of neonatal respiratory problems even if the pregnancy is
at or near term. In a retrospective study of 33,289 term singletons (!37 weeks), Morrison,
et. al. showed that respiratory distress syndrome and transient tachypnea were more likely
to occur in infants delivered by CS than in those delivered vaginally. The OR was 6.8
(95% CI 5.2-8.9) for those delivered by CS before labor and 2.3 (95% CI 1.6-3.5) for
those delivered by CS during labor.2 Also, if the mother presents with uterine
contractions, thought to be spontaneous preterm labor, a policy of planned CS may result
in the delivery of infants at an earlier gestational age, thus potentially increasing the risks
of morbidity due to prematurity.

2. Timing of Delivery

Multiple gestations mature at a faster rate than singletons. It therefore stands to

reason that they may suffer the consequences of postmaturity at earlier gestational ages.
The effect of this relative postmaturity on multiple gestations is remarkable either in the
presence or absence of IUGR. Sairam noted that the risk of stillbirth increased from
1:3333 at 28 weeks of gestation to 1:69 at 39 or more weeks of gestation. At 39 weeks,
the prospective risk of fetal death in twins was 2.40 (95% CI 1.992.89) versus a neonatal
death rate of 2.05 (95% CI 1.542.72). In triplets, the prospective risk of fetal death
exceeded the neonatal death rate at 36 weeks [4.93 (95% CI 2.67-8.86) versus 1.62 (95%
CI 0.286.50)].4 Given the population-based data showing increased perinatal morbidity
and mortality beginning at 38 to 39 weeks, it seems prudent to consider elective delivery
prior to this gestation.

C. References

1. Hogle KL, Hutton EK, McBrien KA, Barrett JFR, Hanah ME. Cesarean delivery for
twins: A systematic review and meta-analysis. Am J Obstet Gynecol 2003;188:220-227.
2. Morrison JJ, Rennie, JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery
at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol
1995;102:101-106.
3. Sairam S, Costeloe K, Thilaganathan B. Prospective risk of stillbirth in multiple-gestation
pregnancies: A population-based analysis. Obstet Gynecol 2002;100:638-641.
4. Chang EY. Timing of delivery in multiple gestation. Clin Obstet Gynecol 2004;
47(1):237-247.
5. Cesarean Section (Clinical Guideline No. 13). NICE. (www.nice.org.uk) April 2004.
PRELABOR RUPTURE OF MEMBRANES AS INDICATION FOR CESAREAN
SECTION

A. Recommendation

There is no clear evidence or recommendation regarding indication for cesarean

section (CS) in cases of prelabor rupture of membranes (PROM). Routine CS is
not recommended for PROM. (Level I, Grade A)

B. Supporting Evidence

Currently, there appears to be no clear evidence or recommendation regarding

indication for CS in cases of PROM. Predictors of CS for PROM at term was investigated in
a multicenter study involving 72 institutions in six countries, wherein 5041 women were
randomized to induction of labor with oxytocin or prostaglandins or to expectant
management. Strong predictors of cesarean delivery after PROM at term were: nulliparity
(OR 2.81); labor lasting more than 12 hours versus less than 6 hours (OR 2.78); labor lasting
6-12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75);
epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate
monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97);
maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and
meconium staining (OR 1.41).

C. Reference

Peleg D, Hannah ME, Hodnett ED, Foster GA, Willan AR, Farine D. Predictors of cesarean
delivery after prelabor rupture of membranes at term. Obstet Gynecol 1999;93(6):1031-1035.
 PLACENTA PREVIA AS INDICATION FOR CESAREAN SECTION

A. Recommendations

Cesarean section (CS) is recommended for delivery in cases of placenta previa

totalis.1 (Level III, Grade A)

For marginal placenta previa or low-lying placenta, vaginal delivery is a feasible

option if the head rather than the placenta is presenting at the os. However, this
option should only be considered in facilities that have appropriate skilled
physicians, neonatal support, and ample blood products. 1-3 (Level III, Grade B)

Adequate blood products should be made available prior to delivery of placenta

previa.2 (Level II-2, Grade A)

B. Supporting Evidence

CS is required for patients with placenta previa totalis. Bhide et. al, reported on
women with placenta previa and demonstrated that when the placental edge was within 1 cm
of the internal cervical os within 2 weeks of delivery, all patients required a CS. In contrast, if
the placental edge to internal cervical os distance was 2 cm or more, the likelihood of
achieving a vaginal delivery was at least 63%.1 For the latter condition, it is theorized that the
fetal head is able to compress the placenta and lower uterine segment enough to prevent
hemorrhage and allow vaginal delivery.2 Bhide, et. al. proposed that the term placenta previa
should only be used when the placental edge overlapped or was within 2 cm of the internal
cervical os in late pregnancy. If the placental edge was located further than 2 cm but within
3.5 cm from the internal cervical os, the placenta should be termed low-lying. In the latter
case, although there is a good chance of a vaginal delivery, the incidence of post- hemorrhage
remains high. Therefore, a low-lying placenta deserves an attempt at vaginal delivery, but
should warn the clinician of the possibility of hemorrhagic complications, so that appropriate
precautions can be taken.3
Women having a CS for placenta previa are at increased risk of blood loss of greater
than 1000 ml compared to CS for other indications (RR 3.97, 95% CI 3.24- 4.85)2. Hence, the
CS should be carried out by an experienced operator with available blood transfusion
services.

C. References

1. Bhide A, Prefumo F, Moore J, et al. Placental edge to internal cervical os distance in the
late third trimester and mode of delivery in placenta praevia. Br J Obstet Gynecol
2003;110:860864.
2. Reed B, Cyper R, Shields A. Diagnosis and management of placenta previa.
Postgraduate Obstetrics and Gynecology 2008;28(20):1-6.
3. Bhide A, Thilaganathan B. Recent advances in the management of placenta previa. Curr
Opin Obstet Gynecol 2004;16:447-451.
4. Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical
Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report.
London: RCOG Press; 2001.
 INTRAUTERINE GROWTH RESTRICTION AS INDICATION FOR
CESAREAN SECTION

A. Recommendations

Cesarean section (CS) should not routinely be offered for intrauterine growth
restriction (IUGR).2 (Level I, Grade A)

Decision regarding timing and manner of delivery is individualized and is based

on the result of antenatal and intrapartum fetal surveillance.4 (Level III, Grade A)

B. Supporting Evidence

A reported one third of pregnancies with small for gestational age (SGA) fetuses
require cesarean delivery.1 However, there is not enough evidence to evaluate the use of a
policy for elective CS for small babies. In a systematic review by Grant, et. al., babies
delivered by elective CS were less likely to develop respiratory distress syndrome (OR 0.43,
95% CI 0.18-1.0), neonatal seizures (0/39 vs 2/42) and fewer deaths (2/62 vs. 6/60) but these
differences did not reach statistical significance. Mothers, on the other hand, were more likely
to have serous morbidity (OR 6.44, 95% CI 1.48-27.89).2 When the cause of IUGR is chronic
hypoxia, it seems logical to avoid acute hypoxia during labor and delivery.3
No randomized trials have conclusively dealt with the issue of delivery timing across
the whole clinical spectrum of IUGR. In principle, delivery timing is straightforward in the
term fetus when fetal lung maturity has been documented, if there is fetal distress or if the
maternal condition dictates delivery.4

C. References

1. GRIT Study Group. A randomised trial of timed delivery for the compromised preterm
fetus: short term outcomes and Bayesian interpretation. Br J Obstet Gynecol
2003;110:2732.
2. Grant A, Glazener CMA. Elective cesarean section versus expectant management for
delivery of small baby. Cochrane Database Syst Rev 2009; Issue 2.
3. Lin CC. Fetal growth retardation. In: Lin CC, Verp MS, Sabbagha RE, eds. The high-risk
fetus. New York: Springer, 1993:36095.
4. Alberry M, Soothill P. Management of fetal growth restriction. Arch Dis Child Fetal
Neonatal Ed 2007;92:F62F67.
 ABNORMAL FETAL HEART RATE PATTERN AS INDICATION FOR
CESAREAN SECTION

A. Recommendation

Detection of an abnormal fetal heart rate (FHR) pattern (Category III) warrants
immediate intervention, usually through immediate cesarean section (CS).1-6
(Level I, Grade A)

B. Supporting Evidence

Abnormal FHR pattern is identified as the main indication for intrapartum CS.
Different studies support the need for immediate CS when an abnormal FHR pattern is
identified. Overall, there was a significant trend towards neonatal acidosis (pH < 7.2) and 5
minute Apgar score of < 7 in cases with abnormal FHR patterns. Ominous patterns were
associated with increased incidence of neurological morbidity (neonatal encephalopathy) (OR
2.9, 95% CI 1.07-7.77).
A systematic review showed an association between the presence of late
decelerations with reduced Apgar scores and metabolic acidosis. Occurrence of multiple late
decelerations was associated with an increase in odds ratio (OR) of cerebral palsy (OR 3.9,
95% CI 1.7-9.3). The risk was further increased when the late decelerations were
accompanied by reduced baseline variability (OR 3.6, 95% CI 1.9-6.7). These were
predictive of subsequent abnormal neurological outcomes.
Uncomplicated variable decelerations were not associated with poor Apgar scores of
metabolic acidosis. However, variable decelerations with atypical features loss of primary
or secondary rise in baseline rate, slow return to baseline, prolonged increase in secondary
rise in baseline rate, biphasic deceleration, loss of variability during the deceleration, change
in the baseline fetal heart rate pattern - were associated with poor adverse neonatal
outcome.3,4
Presence of prolonged deceleration is associated with poor neonatal outcome.
Systematic reviews showed a correlation with significantly lower mean arterial pH values
compared with controls (pH 7.06 0.07 and 7.09 0.06 compared with 7.24 0.06).
Sinusoidal pattern is observed in cases of fetal anemia. In cases where this is
encountered, fetomaternal hemorrhage must be excluded. Its presence is associated with poor
neonatal outcome.5,6

C. References

1. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of
Child Health and Human Development workshop report on electronic fetal monitoring:
update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal
Nurs 2009;38(1):4-5.
2. Low JA, Victory R, Derrick EJ. Predictive value of electronic fetal monitoring for
interpretation of intrapartum fetal asphyxia with metabolic acidosis. Obstet Gynecol
1999;93;285-291.
3. Ozden S, Demitci F. Significance for fetal outcome of poor prognostic features in fetal
heart rate traces with variable decelerations. Arch Gynecol Obstet 1999;262:141-149.
4. Krebs HB, Petres RE, Dunn LJ. Intrpartum fetal heart rate monitoring: Atypical variable
decelerations. Am J Obstet Gynecol 1983;145:297-305.
5. Modanlou HDS, Freeman RK. Sinusoidal fetal heart rate pattern. Its definition and
clinical significance. Am J Obstet Gynecol 1982;142:1033-1038.
6. Egley CC, Bowes WA Jr, Wagner D. Sinusoidal fetal heart rate pattern during labor. Am
J Perinatol 1991;8:197-202.
7. Berkus MD, Langer O, Samueloff A, Xenakis EM, Field NT. Electronic fetal monitoring:
whats reassuring? Acta Obstet Gynecol Scand 1999;78:15-21.
8. Samueloff A, Langer O, Berkus M, Field N, Xenakis E, Ridgeway L. Is fetal heart rate
variability a good predictor of fetal outcome? Acta Obstet Gynecol Scand 1994;73:39-44.
9. Williams KP, Galerneau F. Interpretation of fetal heart rate pattern in the prediction of
neonatal academia. Am J Obstet Gynecol 2003;188:820-823.
10. RCOG Evidence-based Clinical Guideline No.8. The Use of Electronic Fetal Monitoring.
COG Press 2001.
11. SOGC Clinical Practice Guideline No.112. Fetal Health Surveillance in Labor. JOGC
March 2002.
12. ACOG Practice Bulletin No.70. Interpretation of fetal heart rate monitoring. Obstet
Gynecol 2005;186;1453-1461.
 OPTIMAL DECISION-TO-DELIVERY INTERVAL

A. Recommendations

If an emergency cesarean section (CS) is warranted for an abnormal fetal heart

rate (FHR) pattern or acute fetal compromise, it should be started as quickly as
possible, ideally within 30 minutes.1-6 (Level III, Grade B)

Only in a few instances would delivery have to be achieved much faster than 30
minutes to avoid disability or death because in most cases, delivery after 30
minutes is not associated with adverse fetal outcome.7-9 (Level II-2, Grade B)

B. Supporting Evidence

The Royal College of Obstetricians and Gynaecologists (RCOG) has used 30

minutes as the acceptable standard for delivery of the fetus to be accomplished from the time
the decision to perform CS.1 The American College of Obstetrics and Gynecology (ACOG)
recommends an interval of within 20 to 30 minutes from identification of abnormal FHR
patterns to delivery.2 Despite the fact that there are only a few researches,3,4,5,6 including a
systematic review1, which seem to support this standard, 30 minutes remains the arbitrary
cut-off.
Is the delivery-to-decision interval critical in emergency CS situations? The National
Sentinel for Cesarean Section (NSCS) Audit attempted to answer this question by looking
into the association between decision to delivery interval and maternal and neonatal
outcomes.7
Among newborns delivered abdominally via CS, 586 or 3.4% had an Apgar score
less than 7, while 175 or 1% had an Apgar score less than 4. Unadjusted odds ratio (OR)
showed that babies born within 15 minutes from decision did not have better outcomes than
those born after 30 minutes. Adjusting the OR for primary indication for CS, intrapartum
fetal monitoring, grade of urgency and type of anesthesia, babies delivered within 15 minutes
had five minute Apgar scores of < 7 were not significantly different for babies delivered
between 16 and 75 minutes. If the delivery, however, was performed after 75 minutes, there
was a significantly higher odds of 5-minute Apgar scores < 7 (OR 1.7, 95% CI 1.2-2.4). The
75-minute OR for 5-minute Apgar scores < 4 was 1.4 (95% CI 0.7-2.5) while for stillbirth the
OR was 1.8 (95% CI 0.7-4.2), both not statistically significant.
If 30 minutes was used as the reference group, it was found that there was no
significant difference in the odds of a poor outcome (5-minute Apgar score < 7) between
those born within 30 minutes and those born between 31 and 75 minutes (OR 1.1, 95% CI
0.9-1.4). However, if delivery were done after 75 minutes, there was an 80% significantly
increased odds of a poor outcome (5-minute Apgar score < 7, OR 1.8, 95% CI 1.3-2.4). As
above, the odds for 5-minute Apgar scores < 4 and stillbirths were not statistically different.
It was also found from the NSCS study that mothers who were delivered within 30
minutes (short decision-to-delivery interval) or beyond 75 minutes (long decision-to-delivery
interval), there was a higher likelihood that the mothers will need special care. Comparing the
 adjusted OR of requiring special care after delivery, there was a 50% increase among those
who gave birth after 75 minutes than those who gave birth within 15 minutes (OR 1.5, 95%
CI 1.2-1.8). There was no difference between the odds of this outcome between a delivery
interval of 15 minutes and intervals up to 75 minutes. If the 30-minute interval reference was
used for analysis, there was also a 50% increase in odds of requiring special care among those
who gave birth after 75 minutes compared to 30 minutes (OR 1.6, 95% CI 1.4-1.8).
Comparing maternal outcome in women delivered between 31 and 75 minutes, there was no
significant difference (OR 1.1, 95% CI 0.9-1.2). It should, however, be recognized that this is
a nonspecific maternal morbidity which is influenced by comorbid conditions.7 These data
would, therefore, show that there is no evidence that 30 minutes is a critical threshold in
intrapartum hypoxia.
A 12-month study using a 30-minute decision to delivery interval protocol in CS
showed that the longer the time between decision to delivery, the less the acidemia.8 This is a
finding they found difficult to explain. One theory is that there is increased catecholamine
release and reduced uterine perfusion resulting from maternal anxiety. Another speculation is
that deliveries within 30 minutes include those that necessitated greater urgency of delivery
because of more acute hypoxia like abruptio placenta and profound fetal bradycardia. This
just supports the importance of not compromising maternal health when performing an
emergency CS.
In an observational case series by Tuffnell, et. al., it was showed that the currently
recommended 30-minute interval between decision and delivery is not being achieved in
practice. However, failure to meet the recommendation does not seem to increase neonatal
morbidity.9

C. References

1. Royal College of Obstetricians and Gynaecologists. The use of electronic fetal

monitoring: the use and interpretation of cardiotocography in intrapartum fetal
surveillance. London: RCOG Press, 2001.
2. ACOG technical bulletin. Fetal heart rate patterns: monitoring, interpretation, and
management. Int J Obstet Gynecol 1995;51:6574.
3. Schauberger CW, Rooney BL, Beguin EA, Schaper AM, Spindler J. Evaluating the thirty
minute interval in emergency cesarean sections. J Am Coll Surg 1994;179:151155.
4. Roemer VM, Heger-Romermann G. [Emergency Cesarean sectionbasic data].
[German]. Zeitschrift fur Geburtshilfe und Perinatologie 1992;196:9599.
5. Chauhan SP, Roach H, Naef RW, Magann EF, Morrison JC, Martin JN Jr. Cesarean
section for suspected fetal distress. Does the decision-incision time make a difference? J
Reprod Med 1997;42:347352.
6. Dunphy BC, Robinson JN, Sheil OM, Nicholls JSD, Gillmer MDG. Caesarean section
for fetal distress, the interval from decision to delivery, and the relative risk of poor
neonatal condition. J Obstet Gynecol 1991;11:241244.
7. Thomas, J, Paranjothy, S, and James, D. National cross sectional survey to determine
whether the decision to delivery interval critical in emergency caesarean section. BMJ
2004;328:665667.
8. MacKenzie IZ, Cooke I. Prospective 12-month study of 30-minute decision to delivery
intervals for "emergency" caesarean section. BMJ 2001;322:1334-1335.
9. Tuffnell DJ, Wilkinson K and Beresford N. Interval between decision and delivery by
cesarean section are current standards achievable? Observational case series. BMJ
2001;322:1330-1333.
 HEPATITIS B INFECTION

A. Recommendation

Pregnant women with hepatitis B infection with high infectivity may benefit from
an elective cesarean section (CS) in reducing mother-to-child transmission
(MTCT). However, recommending such mode of delivery should proceed with
extreme caution.1 (Level I, Grade B)

B. Supporting Evidence

A systematic review by Yang, et. al. compared elective CS versus planned vaginal
delivery in preventing MTCT of hepatitis B virus. This study included 4 randomized control
trials (RCT) (n=789). There was strong evidence that elective CS could effectively reduce
the rate of MTCT (CS: 10.5%, vaginal delivery: 28%), with no reported increase in maternal
morbidity. 1
Serological screening for hepatitis B should be offered to all pregnant women.
Hepatitis B immunoglobulin and hepatitis B vaccine reduce MTCT. The vaccine and
immunoglobulin are given to the infant at birth followed by either a one month and six month
dose or at 5 weekly intervals.2,3
Most MTCT occurs at birth or postnatally. Transmission at birth may be due to
microperfusion of maternal blood into the infants circulation during placental separation or
by the infant swallowing maternal blood, amniotic fluid or vaginal secretions at vaginal
birth.4

C. References

1. Yang J, Zen X, Men Y, Zhao L. Elective cesarean section versus vaginal delivery for
preventing mother-to-child transmission of hepatitis B virus a systematic review.
Virology 2008;5:100
2. Wong VC, Ip HM, Reesink HW, Lelie PN, Reerink-Brongers EE, et al. Prevention of the
HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg
and HBeAg by administration of hepatitis-B vaccine and hepatitis-B immunoglobulin:
Double-blind randomized placebo-controlled study. Lancet 1984;1:921926.
3. Xu Z-Y, Liu C-B, Francis DP. Prevention of perinatal acquisition of hepatitis B virus
carriage using vaccine: preliminary report of a randomized, double-blind placebo-
controlled and comparative trial. J Pediatr 1985;76:713718.
4. Beasley RP, Trepo C, Stevens CE, Szmuness W. The e antigen and vertical transmission
of hepatitis B surface antigen. Am J Epidemiol 1977;105:9498.
 HERPES SIMPLEX VIRUS

A. Recommendations

When primary genital herpes simplex virus (HSV) infection is acquired during the
first two trimesters of pregnancy, it is advisable to carry out sequential viral
cultures on genital secretions from 32nd week of gestation. If two consecutive
cultures are negative and there are no active herpetic genital lesions at the time of
delivery, it is possible to perform a vaginal delivery.1 (Level II-3, Grade B)

In cases where it is not possible to have viral cultures, in the absence of active
herpetic lesions at the time of delivery, it is possible to perform vaginal delivery.
(GPP)

Pregnant women with primary genital HSV infection detected in the third
trimester of pregnancy should be offered planned cesarean section (CS).2-6 (Level
III, Grade C)

In cases where affected pregnant patients are seen in labor with ruptured
membranes, the CS should be performed as quickly as possible within 46 hours
after membranes rupture. (Level III, Grade C)

In cases where affected pregnancy patients are seen at time when vaginal delivery
is irreversible, a maternal and neonatal intravenous acyclovir therapy is
recommended.10-12 (Level I, Grade B)

Pregnant women with nonprimary HSV at time of birth should not routinely be
offered planned CS.4,7,8 (Level II-3, Grade C)

B. Supporting Evidence

1. Primary HSV Infection and Mother-to-Child Transmission (MTCT) of HSV

For pregnant patients who acquired the primary infection during the first 2
trimesters of pregnancy and had seroconversion completed at the time of delivery, the
risk of HSV transmission to the fetus is low. At this time, the fetus is expected to be
protected by maternal antibodies.1
One case series involving 101 pregnant women with HSV (both primary and
recurrent disease) found the risk of neonatal herpes to be highest for women who
acquired primary infection during the third trimester (3 cases of neonatal infection out of
9 cases of exposure).2 Another study identified 94 women who acquired HSV during
pregnancy but with no MTCT to the infants. There were 9 women who acquired genital
 HSV near the onset of labor and in this group, 4 of the 9 infants developed neonatal HSV
infection.3 A study of 15,923 asymptomatic women in early labor reported isolating
HSV from 56 women. 18 women (35%) had a primary infection and neonatal HSV
developed in 6 infants (33%).4 None of the studies are large enough to address the effect
of mode of birth on MTCT.
Despite limited evidence there is consensus about current practice to offer CS for
primary infection during the 3rd trimester because of the high mortality associated with
neonatal herpes.5,6

2. Recurrent HSV Infection and History of HSV Infection and MTCT

The risk of neonatal infection with recurrent HSV is lower than with primary
HSV infection (8% with recurrent infection and 33% with primary HSV infection).7,8
Recurrent HSV may not cause symptomatic lesions, for example with cervical ulceration.
A study of 15,923 asymptomatic women in early labor reported isolating HSV from 34
women, neonatal HSV developed in 1 of the infants (3%).4 To prevent MTCT of HSV in
asymptomatic women antenatal screening using HSV cultures was proposed, but this test
also did not predict infants risk at birth.9
Three randomized control trials (RCT) evaluate using oral acyclovir from 36
weeks to prevent recurrence of HSV at the time of birth. These found a reduction in CS
for HSV, however do not report the effect of acyclovir on MTCT.10-12

E. References

1. Anzivino E, Fioriti D, Mischitelli M, Bellizzi A, Barucca V, et. al. Herpes simplex virus
infection in pregnancy and in neonate: status of art of epidemiology, diagnosis, therapy
and prevention. Virology 2009;6:40.
2. Nahmias AJ, Josey WE, Naib ZM, Freeman MG, Fernandez RJ, Wheeler JH. Perinatal
risk associated with maternal genital herpes simplex virus infection. Am J Obstet Gynecol
1971;110:825834.
3. Brown ZA, Selke S, Zeh J, Kopelman J, Maslow A, et al. The acquisition of herpes
simplex virus during pregnancy. N Engl J Med 1997;337:509515.
4. Brown ZA, Benedetti J, Ashley R, Burchett S, Selke S, et al. Neonatal herpes simplex
virus infection in relation to asymptomatic maternal infection at the time of labor. N Engl
J Med 1991;324:12471252.
5. Royal College of Obstetricians and Gynaecologists. Management of genital herpes in
pregnancy. Guideline No. 30. London: RCOG Press; 2002.
6. Brocklehurst P, Carney O, Ross E, Mindel A. The management of recurrent genital
herpes infection in pregnancy: a postal survey of obstetric practice. Br J Obstet Gynecol
1995;102:791797.
7. Prober CG, Sullender WM, Yasukawa LL, Au DS, Yeager AS, Arvin AM. Low risk of
herpes simplex virus infections in neonates exposed to the virus at the time of vaginal
delivery to mothers with recurrent genital herpes simplex infections. N Engl J Med
1987;316:240244.
8. Catalano PM, Merritt AO, Mead PB. Incidence of genital herpes simplex virus at the time
of delivery in women with known risk factors. Am J Obstet Gynecol 1991;164:1303
1306.
9. Arvin AM, Hensleigh PA, Prober CG, Au DS, Yasukawa LL, Wittek AE, et. al. Failure
of antepartum maternal cultures to predict the infants risk of exposure to herpes simplex
virus at delivery. N Engl J Med 1986;315:796800.
10. Brocklehurst P, Kinghorn G, Carney O, Helsen K, Ross E, Ellis E, et. al. A randomised
placebo controlled trial of suppressive acyclovir in late pregnancy in women with
recurrent genital herpes infection. Br J Obstet Gynecol 1998;105:275280.
11. Scott LL, Sanchez PJ, Jackson GL, Zeray F, Wendel GD Jr. Acyclovir suppression to
prevent cesarean delivery after first-episode genital herpes. Obstet Gynecol 1996;87:69
73.
12. Braig S, Luton D, Sibony O, Edlinger C, Boissinot C, Blot P, et. al. Acyclovir
prophylaxis in late pregnancy prevents recurrent genital herpes and viral shedding. Eur J
Obstet Gynecol Reprod Biol 2001;96:5558.
 HUMAN IMMUNODEFICIENCY VIRUS INFECTION

A. Recommendation

Pregnant women with human immunodeficiency virus (HIV) infection should be

offered a planned cesarean section (CS) as it reduces the risk of mother-to-child
transmission (MTCT) of HIV.1-3 (Level I, Grade A)

B. Supporting Evidence

A systematic review of interventions to reduce MTCT of HIV included a study,

which compared planned CS at 38 weeks versus planned vaginal birth. This international
multicentre randomized control trial (RCT) shows a significant reduction in the MTCT of
HIV with planned CS (RR 0.17, 95% CI 0.05-0.55).1,2 Similar proportions of women were on
antiretroviral treatment between the groups. None of the women breastfed their infants.
Secondary non-intention to treat (ITT) analysis by actual mode of birth revealed a 70%
reduction in infection of the infant with HIV with elective CS (OR 0.3, 95% CI 0.1-0.8) but
no reduction with emergency CS (OR 1.0, 95% CI 0.3-3.7).3
Observational studies in women taking zidovudine who were delivered by CS and in
women on antenatal antiretroviral treatment who have low viral loads (less than 400
copies/ml) show an MTCT of less than 1% . There was a five-fold reduction in transmission
in women taking zidovudine who were delivered by CS.4
Maternal disease status is an important predictor of MTCT. The maternal viral load
correlates with disease progression and the risk of MTCT. Highly active antiretroviral
therapy (HAART) using three or more antiretroviral drugs are more effective in reducing
viral load especially in women who have advanced disease than single agents such as
zidovudine.5,6 The threshold below which transmission will not occur is still unknown.
While studies have shown that CS is protective in women with no therapy or on zidovidine
alone, the effect of CS for women taking HAART who have low viral loads has not been
evaluated. Current guidelines recommend that women are offered CS.5,7
CS is associated with known operative risks. However, there were no serious
complications in the two groups in the RCT comparing planned CS to planned vaginal birth.
Cohort and cross sectional studies give conflicting data. Some studies report increased
morbidity after CS in HIV-positive women compared to women who do not have HIV (OR
3.7 for major complications, 95% CI 1.4-9.6 and OR 1.3 for minor complications, 95% CI
0.3-4.9).8,9 However HIV positive women with normal CD4 counts did not differ from HIV-
negative women.10 There was no difference in incidence of morbidity nor in severity of
morbidity after CS in other studies.9,11

C. References

1. Brocklehurst P. Interventions aimed at decreasing the risk of mother to child transmission

of HIV infection. Cochrane Database Syst Rev 2009; Issue 2.
2. Lyall EG, Blott M, de Ruiter A, Hawkins D, Mercy D, etl.al. Guidelines for the
management of HIV infection in pregnant women and the prevention of mother-to-child
transmission. HIV Medicine 2001;2:314334.
3. The European Mode of Delivery Collaboration. Elective caesarean-section versus vaginal
delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. Lancet
1999;353:10351039.
4. Mandelbrot L, Le Chenadec J, Berrebi A, Bongain A, Benifla JL, et. al. Perinatal HIV-1
transmission: Interaction between zidovudine prophylaxis and mode of delivery in the
french perinatal cohort. JAMA 1998;280:5560.
5. Health Protection Agency. Renewing the Focus: HIV and other Sexually Transmitted
Infections in the United Kingdom in 2002. Annual Report, November 2003.
[www.hpa.org.uk/infections/topics_az/hiv_and_sti/
publications/annual2003/annual2003.htm].
6. Public Health Service Task Force. Recommendations for use of antiretroviral drugs in
pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal
HIV-1 transmission in the United States, November 26, 2003.
[http://aidsinfo.nih.gov/guidelines/perinatal/ PER_112603.html]. Accessed 18 March
2004.
7. Determinants of mother to infant human immunodeficiency virus 1 transmission before
and after the introdution of zidovudine prophylaxis. Arch Pediatr Adolesc Med
2002;156:915921.
8. Grubert TA, Reindell D, Kastner R, Lutz-Friedrich R, Belohradsky BH, Dathe O.
Complications after caesarean section in HIV-1-infected women not taking antiretroviral
treatment. Lancet 1999;354:16121613.
9. Rodriguez EJ, Spann C, Jamieson D, Lindsay M. Postoperative morbidity associated with
cesarean delivery among humanimmunodeficiency virus-seropositive women. Am J
Obstet Gynecol 2001;184:11081111.
10. Maiques-Montesinos V, Cervera-Sanchez J, Bellver-Pradas J, Abad-Carrascosa A, Serra-
Serra V. Post-cesarean section morbidity in HIV-positive women. Acta Obstet Gynecol
Scand 1999;78:789792.
11. Urbani G, de Vries MM, Cronje HS, Niemand I, Bam RH, Beyer E. Complications
associated with cesarean section in HIV-infected patients. Int J Obstet Gynecol
2001;74:9-15.
 MATERNAL REQUEST FOR CESAREAN SECTION

A. Recommendations

If a patient requests for cesarean section (CS) without a clear indication, the
reason for the request should be examined, discussed, and documented. The
discussion should include the overall benefits and risks of cesarean delivery
compared with vaginal birth.6-7 (Level III, Grade C)

If the reason for the maternal request for CS is fear of childbirth, the obstetrician
should take the time to talk to the patient or to offer counseling in order to help
her address her fears.5 (Level III, Grade C)

It is the option of the clinician to refuse to do the CS and to refer the patient to
another doctor for second opinion.9 (Level III, Grade C)

Should the obstetrician agree to an elective CS, a well-written informed consent,

approved by the Institutional Ethical Review Board (IRB), should be signed by
the patient prior to conduct of the elective CS. (Level III, Grade C)

B. Supporting Evidence

The International Federation of Gynecology and Obstetrics (FIGO) Committee for

the Ethical Aspects of Human Reproduction firmly states that because hard evidence of net
benefit does not exist, performing CS for nonmedical reasons is ethically not justified.1 The
American College of Obstetricians and Gynecologists (ACOG), on the other hand, has stated
that, If the physician believes that cesarean delivery promotes the overall health and welfare
of the woman and her fetus more than vaginal birth, he or she is ethically justified in
performing a CS. Similarly, if the physician believes that performing a cesarean delivery
would be detrimental to the overall health and welfare of the woman and her fetus, he or she
is ethically obliged to refrain from performing the surgery.2 Until such time when quality
evidence becomes available, any decision to perform CS on maternal request should be
carefully individualized and consistent with ethical principles.
The rising trend of CS rates has been partly attributed mostly by clinicians to the
increasing request from patients for cesarean delivery. A systematic review included twelve
observational studies (n=13,285).3 It was found that few women request a CS in the absence
of current or previous obstetric complications. The rates of preference for CS expressed by
the women that were surveyed during pregnancy in UK, Australia and Sweden range from
6% to 8%. Most had a current obstetric complication or experienced a previously complicated
delivery (p<0.001). Only 0.3% preferred a CS without a current or previous medical
complication.4 Women who preferred a CS were more likely to have experienced a previous
CS and have negative feelings about it. One casecontrol study found that women who
requested elective CS due to fear of child birth were more likely to have also experienced a
 spontaneous miscarriage (OR 1.73, 95% CI 1.05-2.85), a longer time between pregnancies
(OR 1.44, 95% CI 1.19-1.75), a longer duration of second stage of labor and a previous
assisted vaginal birth (OR 4.50, 95% CI 2.18-9.31) or emergency CS (OR 26.91, 95% CI
11.86-61.07).5
Another review using available research data between 2000 and 2005 showed
evidence of very small numbers of women requesting a CS; this despite the possible
methodological flaws of overreporting womens request for CS. The reasons for the request
ranged from personal and cultural reasons, including fear of birth and perceived inequality
and inadequacy of care.6 No woman requested CS in the absence of, what she considered,
clinical or psychological indications. The major factor affecting their decision to choose CS
as the mode of delivery appears to be fear for the child and for their own safety. They believe
that CS is the safest for themselves and their babies. It, therefore, becomes imperative for the
obstetricians to address these fears by taking the time to talk to them about it. Despite the few
numbers who requested for cesarean delivery, this has often been cited by obstetricians as the
reason behind the rising incidence of cesarean delivery.7 This was believed by some to divert
attention from physician-led influences on the rising CS rate.
The most recent systematic review was conducted by the RTI International-
University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC
EPC). The group systematically reviewed the evidence on the trend and incidence of cesarean
delivery in the United States and in other developed countries, maternal and infant outcomes
of cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery,
factors affecting the magnitude of the benefits and harms of CDMR, and future research
directions.8 There were 13 studies for trends and incidence of CDMR, 54 for maternal and
fetal outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be
increasing. However, again the authors acknowledge that this incidence is very difficult to
quantify because currently CDMR is not a well-recognized clinical entity nor an accurately
reported indication for diagnostic coding or reimbursement. Their comprehensive assessment
on the different outcomes suggests no major difference between CDMR and planned vaginal
delivery. The evidence is still considered too weak to make definitive conclusions on the
benefits and risks of CDMR compared to planned vaginal delivery.
Bettes, et. al. evaluated obstetricians knowledge, opinions and practice patterns
related to CDMR (N=699 respondents). In the study, obstetricians admit to 20% increased
counseling for patients who requested for unindicated cesarean delivery. Many obstericians
express discomfort with performing unindicated cesarean delivery. Although the
obstetricians agree that the patients have the right to request cesarean delivery, only half have
actually performed one or more CDMR. In addition, only about one fifth would seek or
recommend on for herself or his spouse.9 If in good conscience the obstetrician feels there is
no compelling reason to assent to the patients request for a CS with no maternal or obstetric
indication, she may refer the patient to another clinician for second opinion.

C. References

1. Schenker JG, Cain JM. FIGO Committee Report. FIGO Committee for the Ethical
Aspects of Human Reproduction and Womens Health. International Federation of
Gynecology and Obstetrics. Int J Obstet Gynecol 1999;64:317322.
2. American College of Obstetricians and Gynecologists. Surgery and Patient Choice. In:
Ethics in Obstetrics and Gynecology. 2nd ed. Washington, DC: ACOG 2004:2125.
3. Gamble JA, Creedy DK. Womens request for a cesarean section: a critique of the
literature. Birth 2000;27:256263.
4. Gamble JA, Creedy DK. Womens preference for a cesarean section: incidence and
associated factors. Birth 2001;28(2):101-110.
5. Saisto T, Ylikorkala O, Halmesmaki E. Factors associated with fear of delivery in second
pregnancies. Obstet Gynecol 1999;94:679682.
6. McCourt C, Weaver J, Statham H, Beake S, Gamble J, Creedy DK. Elective cesarean
section and decision making: a critical review of the literature. Birth 2007;34(1):65-79.
7. Weaver JJ, Statham H, Richards M. Are there "unnecessary" cesarean sections?
Perceptions of women and obstetricians about cesarean sections for nonclinical
indications. Birth. 2007;34(1):32-41.
8. Viswanathan M, Visco AG, Hartmann K, Wechter ME, Gartlehner G, et. al. Cesarean
delivery on maternal request. Evid Rep Technol Assess 2006;(133):1-138.
9. Bettes BA, Coleman VH, Zinberg S, Spong CY, Portney B, et. al. Cesarean Delivery on
Maternal Request: Obstetrician-gynecologists Knowledge, Perception and Practice
Patterns. Obstet Gynecol 2007;109:57-66.
10. Cesarean Delivery on Maternal Request, Structured Abstract. March 2006. Agency for
Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/tp/cesarreqtp.htm
11. NIH Consensus Statements. 2006;23(1):1-29.
 PRENATAL PROVISION OF INFORMATION REGARDING CESAREAN
SECTION

A. Recommendations

Patients who have definite indications for abdominal delivery during the antenatal
period should be informed of the indications, procedure, risks, benefits, anesthesia
coverage, and the implications on future pregnancy.1-4 (Level I, Grade A)

Provision of information regarding cesarean section (CS) in order to encourage

women to attempt vaginal birth after cesarean section (VBAC) showed no effect
on preferred mode of delivery.4 (Level I, Grade B)

Information for women considering a VBAC should include: risks of VBAC and
elective CS, warning signs in labor, philosophy and policies of hospital and staff,
strategies to improve chances of success, and information about probability of
success with specific care givers.8-10 (Level I, Grade A)

Identification of risk factors associated with failed trial of labor is mandatory in

selecting patients for VBAC. (Level I, Grade A)

B. Supporting Evidence

1. General Information Regarding CS

The two important reasons for providing women evidence-based information

about CS are (1) to guide women in making decisions regarding the surgery and (2) to
help them be cognizant of their care needs should they undergo a CS.1-2 Connor, et. al.
has shown that provision of decision aids improve awareness of options and outcomes
causing more realistic expectations, reduce decisional disagreements associated with
feeling uninformed, and stimulate an active role in decision-making.3 A randomized
control trial (RCT) (n=227) by Shorten, et. al. showed that women who received decision
aid about the mode of delivery after CS demonstrated a significantly greater increase in
mean knowledge about birth options (increased by 2.17 vs. 0.42 points, p < 0.001, 95%
CI 1.15-2.35) and a significant reduction in decisional conflicts (p < 0.5). However, this
does not result into a consistent preference for a particular mode of delivery.4
Medicolegal pressures are also affected by information regarding CS.5,6
Obstetricians generally believe that these women may be expecting too much, leading to
lawsuits if the birth is associated with complications. Obstetricians would thus be
inclined to practice defensively by performing a CS, which may not be indicated.7
A systematic review was conducted which included either pregnant women who
have previously delivered by CS, or those with a specific indication for CS. The
 objectives were to examine the effectiveness of the provision of information for pregnant
women about cesarean birth on health outcomes, knowledge, impact on decision-making,
information seeking and information needs, and to review the contents of information
provided to pregnant women about CS. Two RCTs involving 1,451 women met the
inclusion criteria for the systematic review. Both studies aimed to reduce cesarean births
by encouraging women to attempt vaginal delivery. One used a program of prenatal
education and support, and the other cognitive therapy to reduce fear. All women in the
Fraser trial8 had a previous cesarean delivery whereas participants in the Saisto trial9
included women who had not previously given birth. Results were not combined because
of differences in the study populations. Nonclinical outcomes were ascertained in both
studies through questionnaires, but were subject to rates of loss to follow-up exceeding
10%. A number of important outcomes cannot be reported: knowledge or understanding,
decisional conflict, and women's perceptions: of their ability to discuss care with
clinicians or family/friends, of whether information needs were met, and of satisfaction
with decision-making. Neither study assessed women's perception of participation in
decision-making about cesarean birth, but Fraser, who examined the effect of study
participation on decision-making, found that women in the intervention group were more
likely to consider that attempting vaginal birth was easier (51% compared to 28% in
control group), or more difficult (10% compared to 6%). These results are possibly
subject to bias. Neither intervention used in these trials made any difference to clinical
outcomes. About 70% or more women attempted vaginal delivery in both trials, yet
cesarean delivery rates exceeded 40%, at least 10% higher than was hoped. There was no
significant difference between control and intervention groups for any of the outcomes
measured: vaginal birth, elective/scheduled cesarean, and attempted vaginal delivery.
Outcome data, although similar for both groups, were not sufficient to compare maternal
and neonatal morbidity or neonatal mortality. There was no difference in the
psychological outcomes for the intervention and control groups reported by either of the
included trials. Consumer reviewers said information for women considering a VBAC
should include: risks of VBAC and elective CS, warning signs in labor, philosophy and
policies of hospital and staff, strategies to improve chances of success, and information
about probability of success with specific care givers.
Research has focused on encouraging women to attempt vaginal delivery. Trials
of interventions to encourage women to attempt vaginal birth showed no effect, but
shortcomings in study design mean that the evidence is inconclusive. Further research on
this topic is urgently needed.

2. Information for Women Considering VBAC

There are two options for the mode of delivery of a pregnant woman who had a
previous cesarean birth: planned elective repeat CS, or planned vaginal birth. Enough
information during the antenatal period must be provided to allow the woman enough
preparation for the proper timing of the procedure.
A systematic review by Rossi, et. al. compared maternal morbidity with planned
VBAC, compared with elective CS. This study showed that trial of labor after a previous
CS is a feasible option, with a success rate of 73%. The incidence of maternal morbidity
is similar in women undergoing VBAC and those choosing elective CS. The risk of
uterine rupture is 3-fold greater in patients planning VBAC compared to those
undergoing elective CS, however, the risks of blood transfusions and hysterectomy are
the same in both birth options.3 This study showed that the higher risk of uterine rupture
 in women planning VBAC is counterbalanced by the reduction in maternal mobility,
uterine rupture and hysterectomy when VBAC is successful.10
Studies have focused on identifying risk or predictive factors of unsuccessful
VBAC. Good predictors for successful trial of labor include maternal age less than 40, a
history of previous spontaneous vaginal delivery before the initial CS, cervical dilatation
greater than 4 cm at admission, birthweight less than 4000 g. On the other hand, a history
of dystocia, multiple prior CS, alcohol and cigarette use, cephalopelvic disproportion and
obesity are associated with failure of VBAC and increased morbidity.1

C. References

1. Horey D, Weaver J, Russell H. Information for pregnant women about caesarean birth.
Cochrane Database Syst Rev 2009;Issue 2.
2. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat
caesarean section versus planned vaginal birth for women with a previous caesarean
birth. Cochrane Database Syst Rev 2009;Issue 2.
3. O'Connor AM, Bennett CL, Stacey D, Barry M, Col NF, et. al. Decision aids for people
facing health treatment or screening decisions. Cochrane Database Syst Rev 2009;Issue
2.
4. Shorten A, Shorten B, Keogh J, West S and Morris J. Making choices for childbirth: A
randomized control trial of a decision-aid for informed birth after cesarean. Birth
2005;32(4):252-261.
5. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical
Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG
Press, 2001.
6. Johanson R, Newburn M, McFarlane A. Has the medicalisation of childbirth gone too
far? BMJ 2002;324(7342):892-895.
7. Commonwealth Department of Human Services and Health. Review of professional
indemnity arrangements for health care professionals (Tito F, chair). Compensation and
professional indemnity in health care: a final report. Canberra: Australian Government
Publishing Service, 1995.
8. Fraser W, Maunsell E, Hodnett E, Moutquin JM. Randomized controlled trial of a
prenatal vaginal birth after cesarean section education and support program. Am J
Gynecol Obstet 1994;176(2):419-425.
9. Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized
controlled trial of intervention in fear of childbirth. Obstet Gynecol 2001;98(5):820-826.
10. Rossi AC, DAddario V. Maternal morbidity following a trial of labor after cesarean
section vs. elective repeat cesarean delivery: a systematic review with metaanalysis. Am J
Obstet Gynecol 2008.
 OPTIMAL TIME OF PLANNED CESAREAN SECTION

A. Recommendations

Elective cesarean section (CS) should be scheduled at 39 weeks gestation.1,2,5

(Level II-1, Grade B)

Elective CS should be undertaken before 39 weeks gestation if there is an

obstetric or medical indication. (Level III, Grade C)

Patients should be informed of the possibility of labor prior to the scheduled

elective CS, and should be advised to immediately consult once with signs of
labor. (Level III, Grade B)

B. Supporting Evidence

A cross-sectional study done in the north of England (n=179,701) showed that 0.08%
(n=149) of babies born 34 weeks age of gestation or more had respiratory distress syndrome
(RDS) requiring ventilatory support and without any evidence of aspiration or intrapartum
infection. Of these babies, " (n=36) were already actually 37 weeks or older, but 88% (n=32)
were born by planned CS. This shows that babies who are considered term and mature by
internationally agreed definition by reaching 37 weeks age of gestation, can develop
potentially lethal pulmonary immaturity at birth, particularly if born by planned CS prior to
labor. Furthermore, those born at 37-38 weeks are 120x at greater risk of developing RDS
than those born at 39-41 weeks.1
A large prospective observational study (n=33,289) attempted to establish whether
the timing of delivery between 37 to 42 weeks age of gestation influences the respiratory
outcome in order to guide obstetricians on the appropriate timing of planned CS at term.2 All
cases of RDS or transient tachypnea of the newborn (TTN) requiring neonatal intensive care
unit (NICU) admission were collected over nine years. The incidence of RDS is 0.22% (95%
CI 1.7-2.7) while the incidence of TTN was 0.57% (95% CI 4.9-6.5). Respiratory morbidity
was significantly higher for newborns delivered by CS prior to the onset of labor (0.35%)
compared with those born by CS during labor (0.53%) (OR 2.0, 95% CI 5.2-8.9, p < 0.001).
There was a significant trend towards decreasing relative risk for respiratory morbidity for
delivery by prelabor CS during 37 to 37 6/7 weeks versus 38 to 38 6/7 weeks (RR 1.74, 95%
CI 1.1-2.8, p < 0.02) and during 38 to 38 6/7 weeks compared to 39 to 39 6/7 weeks (RR 2.4,
95% CI 1.2-4.8, p < 0.02). From the National Sentinel Cesarean Section (NSCS) Audit data,
about 10% of pregnant women go into labor prior to 39 weeks. The average planned CS rate
is about 10%. Therefore about 1% of women about to undergo planned CS after 39 weeks
may go into labor prior to that time. It is estimated that for a hospital with about 3,000
deliveries per year, performing planned CS at or after 39 weeks will prevent 1 case of TTN or
RDS per year, but would increase unscheduled CS rate by 10%.
 Other studies but with a retrospective nature using a perinatal database showed the
same findings. A 5-year study in the Netherlands gave a 5.1% incidence of respiratory
problems for neonates born by CS after 37 weeks gestation. The relative risk is significantly
decreased with CS delivery at 38-42 weeks compared with 37-38 weeks (RR 0.14, 95% CI
0.03-0.64, p < 0.001).3 Zanardo showed in a 3-year study that neonatal respiratory odds ratio
was significantly higher in the group delivered by elective CS compared with vaginal
delivery (OR 2.6, 95% CI 1.35-5.9, p < 0.01). After 39 weeks though there was no significant
difference in risk of RDS between the two groups.4
Recently, a systematic review was conducted to assess the relationship between
delivery by elective CS and respiratory morbidity in the term and near-term newborn.4
Medline, Embase, Cochrane and Web of Science databases were searched. There were nine
studies eligible for inclusion. However, a pooled risk estimate cannot be established because
the methodology of the studies varied. All studies found that delivery by planned CS
compared with vaginal delivery increased the risk of respiratory morbidities in the newborn,
albeit in some studies it was not statistically significant. While some studies presented much
higher risk estimates, the overall risk of respiratory morbidities is increased about 2-3x, even
among deliveries after 37 completed weeks.

C. References

1. Madar J, Richmond S, Hey E. Surfactant-deficient respiratory distress after elective

delivery at term. Acta Paediatr 1999;88:12441248.
2. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery
at term: influence of timing of elective caesarean section. Br J Obstet Gynecol
1995;102:101106.
3. Graziosi GC, Bakker CM, Brouwers HA, Bruinse HW. Elective cesarean section is
preferred after the completion of a minimum of 38 weeks of pregnancy. Ned Tijdschr
Geneeskd. 1998;142(42):2300-2303.
4. Zanardo V, Simbi AK, Franzoi M, Sold G, Salvadori A, Trevisanuto D. Neonatal
respiratory morbidity risk and mode of delivery at term: influence of timing of elective
caesarean delivery. Acta Paediatr 2004;93(5):643-647.
5. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Elective caesarean section and
respiratory morbidity in the term and near-term neonate. Acta Obstet Gynecol Scand
2007; 86(4):389-394.
 ROUTINE LABORATORY TESTS FOR CESAREAN SECTION

A. Recommendations

Routine laboratory test during cesarean section (CS) include hematocrit and
indirect Coombs. (Level III, Grade C)

For those without documented blood typing on antenatal check-up, it should also
be requested on admission. (GPP)

B. Supporting Evidence

Search of the literature for the past 10 years has not yielded any study on routine
laboratory tests for CS. The 22nd edition of Williams Obstetrics recommends that the
hematocrit be rechecked and indirect Coombs test requested. If the latter is positive, then
availability of compatible blood must be assured.

C. Reference

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. 22nd edition
Williams Obstetrics. McGraw-Hill 2005, p 603.
 PROPHYLACTIC ANTIBIOTICS

A. Recommendations

Antibiotic prophylaxis is recommended in women about to undergo cesarean

section (CS).1 (Level I, Grade A)

A single dose of ampicillin or first generation cephalosporin is recommended.2

(Level I, Grade A)

The antibiotic prophylaxis may be administered preoperatively or after cord

clamping.8 (Level I, Grade A)

B. Supporting Evidence

Antibiotic prophylaxis is administered prior to operation to reduce the risk of post-

operative infections. These include wound infection, postpartum endometritis and urinary
tract infection. One systematic review evaluates the use of antibiotic prophylaxis and
infectious complications with CS.1 This review included 81 randomized control trials (RCT)
(n=11,957). 48 RCTs included women having either elective or non-elective CS (n=6,788),
12 RCTs included women having elective CS (n=2,037), and 23 RCTs included women
having non-elective CS (n=2,132). The use of prophylactic antibiotics with CS results in a
reduction in the incidence of episodes of fever (RR 0.45, 95% CI 0.39-0.52), endometritis
(RR 0.39, 95% CI 0.34-0.43), wound infection (RR 0.41, 95% CI 0.35-0.48), urinary tract
infection (RR 0.54, 95% CI 0.46-0.64) and serious infection (RR 0.42, CI 0.28-0.65).
The effectiveness of different antibiotic regimens was evaluated in a systematic
review which included 51 RCTs.2 There is no advantage in using a multiple dose regimen
compared with a single dose (OR 0.92, 95% CI 0.70-1.23). There was no difference in the
efficacy of ampicillin compared with first generation cephalosporins (OR 1.27, CI 0.84-1.93).
There was also no difference between first generation compared with second or third
generation cephalosporins (OR 1.21, 95% CI 0.97-1.51).
RCTs on the use of intra-abdominal lavage with saline, intrauterine lavage with
antibiotics, preoperative skin preparation and vaginal preparation with povidone iodine to
reduce infectious morbidity at CS have been done.4,5,6 These methods showed no effect in
reducing infectious morbidity. RCTs on pelvic washing with antibiotic solution and the use
of intravaginal metronidazole showed a reduction in infectious morbidity but the numbers
were small.5,7
One RCT (n=90) evaluates the occurrence of postoperative infection in pregnant
women given a single dose of antibiotic at skin incision or after cord clamping. The rates of
endometritis (RR 0.67, 95% CI 0.42-1.07), wound infection (RR 0.84, 95% CI 0.45-1.55),
neonatal sepis (RR 1.28, 95% CI 0.91-1.79), and neonatal intensive care unit (NICU)
admissions (RR 1.28, 95% CI 0.91-1.79) were similar between the 2 groups. There was no
 difference in infectious morbidity whether antibiotic prophylaxis was given before skin
incision or at cord clamping.8

C. References

1. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database
Syst Rev 2009; Issue 2.
2. Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for caesarean section.
Cochrane Database Syst Rev 2009; Issue 2.
3. Harrigill KM, Miller HS, Haynes DE. The effect of intraabdominal irrigation at cesarean
delivery on maternal morbidity: a randomized trial. Obstet Gynecol 2003;101:8085.
4. Lewis DF, Otterson WN, Dunnihoo DR. Antibiotic prophylactic uterine lavage in
cesarean section: a double-blind comparison of saline, ticarcillin, and cefoxitin irrigation
in indigent patients. South Med J 1990;83:274276.
5. Magann EF, Dodson MK, Ray MA, Harris RL, Martin JN Jr, Morrison JC. Preoperative
skin preparation and intraoperative pelvic irrigation: impact on post-cesarean
endometritis and wound infection. Obstet Gynecol 1993;81:922925.
6. Reid VC, Hartmann KE, MCMahon. Vaginal preparation with povidone iodine and
postcesarean infectious morbidity: a randomized controlled trial. Obstet Gynecol
2001;97:147152.
7. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the
prevention of postcesarean endometritis: a randomized controlled trial. Obstet Gynecol
2001;98:745750.
8. Thigpen BD, Hood WA, Chauhan S, Bufkin L, Bofill J, et. al. Timing of prophylactic
antibiotic administration in the uninfected laboring gravida: a randomized clinical trial.
Am J Obstet Gynecol 2005;192(6):1864-1868.
 SHAVING

A. Recommendations

Pre-operative shaving of the site is not routinely recommended. However if it is

necessary to remove hair then it is preferable to use clippers rather than shaving
with a razor as this results in fewer surgical site infections. (Level I, Grade A)

Removing hair before surgery using depilatory cream results in fewer surgical site
infections than shaving. (Level I, Grade A)

B. Supporting Evidence

A Cochrane Systematic Review evaluated preoperative hair removal to reduce

surgical site infection (SSI). Eleven randomized control trials (RCT) were included in this
review. Three trials involving 625 people compared hair removal using either depilatory
cream or razors with no hair removal and found no statistically significant difference between
the groups in terms of SSI. No trials were identified which compared clipping with no hair
removal. Three trials involving 3,193 people compared shaving with clipping and found that
there were statistically significantly more SSI when people were shaved rather than clipped
(RR 2.02, 95% CI 1.21-3.36). Seven trials involving 1,213 people compared shaving with
removing hair using a depilatory cream and found that there were statistically significantly
more SSI when people were shaved than when a cream was used (RR 1.54, 95% CI 1.05-
2.24). No trials were found that compared clipping with a depilatory cream. One trial
compared shaving on the day of surgery with shaving the day before surgery and one trial
compared clipping on the day of surgery with clipping the day before surgery; neither trial
found a statistically significant difference in the number of SSI. No trials were found that
compared depilatory cream at different times or that compared hair removal in different
settings.

C. Reference

Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site

infection. Cochrane Database Syst Rev 2006; Issue 3.
 ABDOMINAL INCISION

A. Recommendation

Transverse abdominal incision should be performed during cesarean section (CS).

The transverse incision of choice is the Joel-Cohen incision.1 (Level I, Grade A)

B. Supporting Evidence

A Cochrane review of the different abdominal surgical incisions for CS identified 4

trials involving 666 women. Two studies (n=411) compared the Joel-Cohen incision with the
Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative morbidity
(RR 0.35, 95% CI 0.14-0.87) with the Joel-Cohen incision. One of the trials reported reduced
postoperative analgesic requirements (RR 0.55, 95% CI 0.40-0.76); operating time (weighted
mean difference (WMD) 11.40, 95% CI -16.55 to -6.25); delivery time (WMD 1.90, 95% CI
-2.53 to -1.27); total dose of analgesia in the first 24 hours (WMD 0.89, 95% CI -1.19 to -
0.59); estimated blood loss (WMD 58.00, 95% CI -108.51 to -7.49); postoperative hospital
stay for the mother (WMD 1.50, 95% CI -2.16 to -0.84); and increased time to the first dose
of analgesia (WMD 0.80, 95% CI 0.12-1.48) compared to the Pfannenstiel group. No other
significant differences were found in either trial. The other study (n=97) comparing the
Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in
febrile morbidity (RR 1.26, 95% CI 0.08-19.50); need for blood transfusion (RR 0.42, 95%
CI 0.02-9.98); wound infection (RR 1.26, 95% CI 0.27-5.91); physical tests on muscle
strength at three months postoperative and postoperative hospital stay (WMD 0.40 days, 95%
CI 0.34-1.14).
The conclusion of the study is that the Joel-Cohen incision has advantages compared
to the Pfannenstiel incision. These are less fever, pain and analgesic requirements, less blood
loss, shorter duration of surgery and hospital stay. These advantages for the mother could be
extrapolated to savings for the health system. However, it should be noted that the studies in
the Cochrane review did not include trials comparing vertical and transverse incision. The
studies included in the review compared Pfannenstiel incision with the other types of
transverse incision.

C. References

1. Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane
Database Syst Rev 2007; Issue 1.
2. National Collaborating Centre for Women's and Children's Health. Caesarean section.
London (UK): National Institute for Clinical Excellence (NICE); 2004 Apr. 142
 REMOVAL OF PLACENTA DURING CESAREAN SECTION

A. Recommendation

The placenta should be removed by controlled cord traction instead of manual

extraction as this decreases endometritis.1-9 (Level I, Grade A)

B. Supporting Evidence

There are varied opinions regarding the optimal method for placental removal during
cesarean section (CS). The two methods compared in the randomized control trials (RCT) are
manual removal and controlled cord traction or spontaneous separation of the placenta. The
Royal College of Obstetricians and Gynecologists (RCOG) reports a higher rate of use of
controlled cord traction (73%) compared with manual removal.1,2 There were 9 RCTs that
have studied the outcomes comparing the two methods. Eight of the 9 RCTs included both
blood loss and endometritis as primary outcomes.
The Cochrane Database included 15 studies (n=4694).3 Manual removal of the placenta
was associated with more endometritis (RR 1.64, 95% CI 1.42-1.90; 4134 women, 13 trials);
more blood loss (ml) (weighted mean difference (WMD) 94.42 ml, 95% CI 17.19-171.64;
2001 women, 8 trials); more blood loss > 1000 ml (RR 1.81, 95% CI 1.44-2.28; 872 women,
2 trials); lower hematocrit after delivery (%) (WMD 1.55, 95% CI -3.09 to -0.01; 384
women, 2 trials); greater hematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00-0.78;
1777 women, 5 trials); longer duration of hospital stay (days) (WMD 0.39 days, 95% CI
0.17- 0.61; 546 women, 3 trials). Thus, delivery of the placenta with cord traction at CS has
more advantages compared to manual removal. These are less endometritis, less blood loss,
less decrease in hematocrit levels postoperatively, and shorter duration of hospital stay.
Five of the RCTs were included in a meta-analysis evaluating the outcome of postpartum
endometritis.4,5,6,7,8 There was an increased incidence of endometritis with manual removal of
the placenta compared to spontaneous separation (RR 1.54, 95% CI 1.23-1.92).
Three RCTs reported blood loss as an outcome measure.4,7,9 Meta analysis of these RCTs
showed no difference between manual removal and spontaneous separation of the placenta
(SMD 0.62ml, 95% CI 1.17-2.4).

C. References

1. Tully L, Gates S, Brocklehurst P, McKenzie-McHarg K, Ayers S. Surgical techniques

used during caesarean section operations: results of a national survey of practice in the
UK. Eur J Obstet Gynecol Reprod Biol 2002; 102:120126.
2. Clinical Guideline: Caesarean Section. National Collaborating Center for Womens and
Childrens Health. April 2004
3. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean
section. Cochrane Database Syst Rev 2008; Issue 3.
4. McCurdy CM, Jr, Magann EF, McCurdy CJ, Saltzman AK. The effect of placental
management at cesarean delivery on operative blood loss. Am J Obstet Gynecol1992;
167:1363-1367.
5. Cernadas M, Smulian JC, Giannina G, Ananth CV. Effects of placental delivery method
and intraoperative glove changing on postcesarean febrile morbidity. J Matern Fetal Med
1998; 7:100104.
6. Lasley DS, Eblen A. The effect of placental removal method on the incidence of
postcesarean infections. Am J Obstet Gynecol 1997; 176:12501254.
7. Chandra P, Schiavello HJ, Kluge JE, Holloway SL. Manual removal of the placenta and
postcesarean endometritis. J Reprod Med 2002; 47:101106.
8. Atkinson MW, Owen J, Wren A, Hauth JC. The effect of manual removal of the placenta
on post-cesarean endometritis. Obstet Gynecol 1996; 87:99102.
9. Magann EF, Washburne JF, Harris RL, Bass JD, Duff WP, Morrison JC. Infectious
morbidity, operative blood loss, and length of the operative procedure after cesarean
delivery by method of placental removal and site of uterine repair. J Am Coll Surg 1995;
181:517520.
 CLOSURE OF PERITONEUM IN CESAREAN SECTION

A. Recommendations

Nonclosure of both the visceral and parietal peritoneum after cesarean section
(CS) leads to shorter operative time and less postoperative fever.1 (Level I, Grade
A).

However, the obstetrician should know that nonclosure likewise leads to

increased incidence of adhesions during a second CS.3-4 (Level II-2, Grade B).

B. Supporting Evidence

There are many ways of performing a CS with the technique dependent on the
clinical presentation and the obstetricians preference. Suturing of the peritoneal layers at CS
may or may not be done.
A meta-analysis compared controlled trials leaving the visceral and/or parietal
peritoneum unsutured at CS with a technique which involves suturing the peritoneum in
women undergoing elective or emergency CS. Fourteen trials, involving 2908 women, were
included and analyzed. The methodological quality of the trials was variable. Nonclosure of
the peritoneum reduced operating time whether both or either layer was not sutured. For both
layers, the operating time was reduced by 6.05 minutes (95% CI -6.74 to -5.37). There was
significantly less postoperative fever and reduced postoperative stay in hospital for visceral
peritoneum and for both layer nonclosure. The number of postoperative analgesic doses was
reduced in the peritoneal nonclosure group (weighted mean difference (WMD) -0.20, 95% CI
-0.33 to -0.08). There were no other statistically significant differences. The trend for wound
infection tended to favor nonclosure, while endometritis results were variable. Long-term
follow up in one trial showed no significant differences. The power of the study to show
differences was low. There was improved short-term postoperative outcome if the peritoneum
was not closed. Long-term studies following CS are limited, but data from other surgical
procedures are reassuring. There is at present no evidence to justify the time taken and cost of
peritoneal closure.
Several studies, on the other hand, have shown that nonclosure of the peritoneum is
associated with increased incidence of adhesions on second operation. A retrospective chart
review by Hamel (n=62 cases), showed that closure of the peritoneum resulted in
significantly fewer extensive adhesions when compared to nonclosure (31.2% vs. 70%,
p=0.013).3 A retrospective cohort study (n=612) by Yiyang, et. al.,4 likewise showed that
among women with no parietal closure 16.2% had visceral adhesions, vs. only 8.1% of those
with closure (p=0.0003). Closure of the visceral peritoneum had a similar effect.

C. References
1. Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean
section. Cochrane Database Syst Rev 2003; Issue 4.
2. Berghall V, Baxter JK, and Chauhan SP. Evidence-based surgery for cesarean delivery.
Am J Obstet Gynecol 2005;193:1607-1617.
3. Hamel, KJ. Incidence of adhesions at repeat delivery. American J Obstet Gynecol
2008;e31-32.
4. Yiyang Z, Qunxi C, Weiling W. Closure vs. nonclosure of peritoneum at cesarean
delivery. Int J Gynaecol Obstet 2006;94(2):1037.
 CLOSURE OF SUBCUTANEOUS TISSUE DURING CESAREAN SECTION

A. Recommendations

Closure of the subcutaneous tissue should be performed if the patient has more
than 2 cm subcutaneous fat.1-9 (Level I, Grade A)

The additional use of a subcutaneous drain for subcutaneous thickness of 4 cm or

more is not recommended as it does not prevent postoperative wound
complications.10 (Level I, Grade A)

B. Supporting Evidence

The technique for closure of the abdominal wall during cesarean section (CS) varies
greatly among clinicians. The subcutaneous tissue may be sutured or left unsutured with the
skin sutured directly after the fascia. The rationale for closure of the subcutaneous tissue is
the elimination of space in order to prevent the formation of hematomas or seromas which
may later be foci of infection. On the other hand, leaving the subcutaneous tissue unsutured
will result in faster surgical time, less foreign material that could become a focus of infection,
and greater skin mobility leading to a better-looking scar.
A survey of Royal College of Obstetricians and Gynecologists (RCOG) members
and fellows showed the wide variation in practice among obstetricians: 42% always closed
the subcutaneous fat, 1% sometimes closed it, 21% never closed it, 28% closed it if it was
thick, and 8% closed it if it was thin.1
A Cochrane systematic review assessed the techniques and materials for closure of
the abdominal wall in CS.2 It included 7 studies (n=2056), all of which were assessed to be
generally satisfactory in quality. Six of these randomized control trials (RCT) (n=1853)
looked into the maternal outcomes of closure versus nonclosure of the subcutaneous
fat.3,4,5,6,7,8 There was no difference in the risk of wound infection between the closure and the
nonclosure group (RR 1.02, 95% CI 0.69-1.5). There was a significant decreased risk of
hematoma or seroma formation with subcutaneous fat closure versus nonclosure (RR 0.52,
95% CI 0.33-0.82). The aggregate outcome of wound complication which included one or
more of wound infection, wound separation, hematoma, or seroma, was significantly less
frequent in the closure group (RR 0.68, 95% CI 0.52-0.88). The reviewers, however, felt the
effects on hematoma/seroma may not be robust because its subjective nature in terms of
diagnoses and the fact that wound infection rates were the same in the closure and nonclosure
group. The most common complication, which was seroma may not even cause pathology or
influence the well-being or satisfaction of women or even affect long-term outcomes.
Another meta-analysis attempted to define the role of suture closure of the
subcutaneous fat in preventing wound complications after CS.9 There were 3 RCTs (n=875)
which included patients with any thickness of subcutaneous fat and noted a decreased
incidence of wound disruption with closure (RR 0.56, 95% CI 0.36-0.86). Two RCTs
 (n=181) reported results from patients with subcutaneous depth of 2 cm or less and noted no
difference (RR 1.01, 95% CI 0.46-2.2. Five studies (n=887) had results from patients with
subcutaneous depth greater than 2 cm. Although only 1 study had a significant effect by
itself, the overall relative risk when results were statistically combined demonstrated a
significant decrease in wound disruption (RR 0.66, 95% CI 0.48-0.91). This shows that in
women with subcutaneous thickness greater than 2 cm, subcutaneous closure resulted in a
risk reduction of 6.2% and 16.2% women would need subcutaneous closure to prevent 1
wound disruption (number needed to treat).
A multicenter randomized trial (n=280) evaluated the efficacy of the additional use
of subcutaneous drain in preventing wound complications among women with at least 4 cm
subcutaneous thickness undergoing CS.10 In this study, the composite wound morbidity rate
was 17.4% (25/144) in the suture group and 22.7% (28/124) in the suture plus drain group
(RR 1.3, 95% CI 0.82.1). Individual wound complication rates, including subcutaneous
dehiscence (15.3% vs 21.8%), seroma (9.0% vs 10.6%), hematoma (2.2% vs 2.4%), abscess
(0.7% vs 3.3%), fascial dehiscence (1.4% vs 1.7%), and hospital readmission for wound
complications (3.5% vs 6.6%), were similar (p > 0.05) between women treated with suture
alone and those treated with suture plus drain, respectively. Based on this study, the authors
concluded that the additional use of subcutaneous drain is not effective for the prevention of
wound complications in obese women undergoing cesarean delivery.

C. References

1. Tully L, Gates S, Brocklehurst P, McKenzie-McHarg K, Ayers S. Surgical techniques

used during caesarean section operations: results of a national survey of practice in the
UK. Eur J Obstet Gynecol Reprod Biol 2002;102:120-126.
2. Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in
caesarean section. Cochrane Database Syst Rev 2004; Issue 4.
3. Allaire AD, Fisch J, McMahon MJ. Subcutaneous drain vs. suture in obese women
undergoing cesarean delivery: a prospective, randomized trial. J Reprod Med 2000;
45(4):327-331.
4. Cetin A, Cetin M. Superficial wound disruption after cesarean delivery: effect of the
depth and closure of subcutaneous tissue. Int J Gynecol Obstet 1997; 57(1):17-21.
5. Chelmow D, Huang E, Strohbehn K. Closure of the subcutaneous dead space and wound
disruption after cesarean delivery. J Matern Fetal Med 2002; 11(6):403-408.
6. Del Valle GO, Combs P, Qualls C, Curet LB. Does closure of camper fascia reduce the
incidence of post-cesarean superficial wound disruption? Obstet Gynecol 1992;
80(6):1013-1016.
7. Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin Jr JN, Morrison JC.
Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after
cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002; 186(6):1119-
1123.
8. Naumann RW, Hauth JC, Owen J, Hodgkins PM, Lincoln T. Subcutaneous tissue
approximation in relation to wound disruption after cesarean delivery in obese women.
Obstet Gynecol 1995;85(3):412-416.
9. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound
disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004; 103(5 Pt
1):974-980.
10. Ramsey PS, White AM, Guinn DA, et. al. Subcutaneous tissue re-approximation, alone
or in combination with drain, in obese women undergoing cesarean delivery. Obstet
 Gynecol 2005;105:967-973.

USE OF INDWELLING FOLEY CATHETER IN CESAREAN SECTION

A. Recommendations

An indwelling catheter may be used during cesarean section (CS) without an

increase in morbidity.1-4 (Level I, Grade A)

An indwelling urinary catheter may be removed less than 24 hours after CS.5-9
(Level I, Grade A)

Removal of the urinary bladder catheter should be carried out once a woman is
mobile after a regional anesthetic and not sooner than 12 hours after the last
epidural top up dose.10 (Grade C)

B. Supporting Evidence

1. Urinary Catheter Use at CS

A UK survey of obstetricians reports that for CS with epidural anesthesia, the

majority (82%) use an indwelling urethral catheter for both the procedure and
postoperatively, a minority would use an indwelling catheter for either the duration of the
procedure only (10.6%) or an inout catheter (7.3%). This was similar for either
emergency or planned CS, and for CS with general anaesthesia1. Urinary bladder
catheters are commonly used during CS to prevent damage to the bladder during surgery.
A randomized control trial (RCT) (n=50) of women undergoing elective CS
under epidural analgesia were randomized prospectively to be catheterized with an in-
out or an indwelling urethral catheter removed after the CS. Of the women who had
catheterization for the time of surgery alone, 44% subsequently required re-
catheterization, whereas all women with indwelling catheters voided spontaneously on
their removal. The frequency of significant bacteriuria was the same in both groups2.
Another RCT from Iran (n=270) included women having a CS with general or
regional anesthesia. Women were randomized into two groups: one group was not
catheterized but was encouraged to void urine immediately prior to the CS; another group
had indwelling catheters removed the day after the CS. Of women who were not
catheterized, 4% required catheterization postoperatively. There was no difference in
ambulation time and women who did not have an indwelling catheter had a slightly
shorter hospital stay3.
However, in a prospective comparative study carried out at a private hospital in
Colombo, Sri Lanka involving 50 women, CS without urethral catheterization did not
compromise the safety or ease of surgery. It was found to reduce the risk of urinary
infection4
 2. Urinary Catheter Removal after CS

The effect of urinary bladder catheterization at CS on has been described in a

prospective survey (n=8402) as a risk factor for postpartum urinary retention5.
One RCT compared immediate catheter removal to removal of an indwelling
catheter the next day in women who had a CS under general anesthetic (n=107). They
report no difference in incidence of urinary tract infection (RR 1.64, 95% CI 0.80-3.34)
but more instances of urinary retention with intermittent catheterization (39% vs. 0%)6.
A small RCT compared urinary retention after CS with a general anesthetic to
urinary retention after CS with an epidural anesthetic and found no difference7.
Another RCT (n=78) compared removal of the urinary bladder catheter
immediately postoperatively with removal the next day in women undergoing
gynecological (pelvic) surgery, 29 who had CS. They found no difference in the
incidence of urinary tract infection, urinary retention or fever but the method of
randomization is unclear and data given in the paper is incomplete8.
Locally, in a tertiary government hospital, a prospective RCT of 240 women was
done. The women underwent emergency or elective CS and were randomized to have
their indwelling catheters removed after 24 hours or after 4 hours. The group of women
who had early removal of the urinary catheter experienced less discomfort upon voiding,
had an earlier time to spontaneously void, ambulated early and had a shorter hospital stay
compared to women in the other group. No significant difference was seen for
recatheterization9.

C. References

1. Tully L, Gates S, Brocklehurst P, McKenzie-McHarg K, Ayers S. Surgical techniques

used during caesarean section operations: results of a national survey of practice in the
UK. Eur J Obstet Gynecol Reprod Biol 2002;102:120126.
2. Kerr-Wilson RH MS. Bladder drainage for caesarean section under epidural analgesia. Br
J Obstet Gynecol 1986;93:2830.
3. Ghoreishi J. Indwelling urinary catheters in cesarean delivery. Int J Gynecol Obstet
2003;83:270.
4. Senanayake H. Elective cesarean section without urethral catheterization. J Obstet
Gynecol Res 2005; 31(1): 32-37.
5. Groutz A, Gordon D, Wolman I, Jaffa A, Kupferminc MJ, Lessing JB. Persistent
postpartum urinary retention in contemporary obstetric practice. Definition, prevalence
and clinical implications. J Reprod Med 2001;46:4448.
6. Tangtrakul S, Taechaiya S, Suthutvoravut S, Linasmita V. Post-cesarean section urinary
tract infection: a comparison between intermittent and indwelling catheterization. J Med
Assoc Thai 1994;77:244248.
7. Sharma KK, Mahmood TA, Smith NC. The short term effect of obstetric anaesthesia on
bladder function. J Obstet Gynecol 1994;14:254255.
8. Dunn TS, Forshner D, Stamm C. Foley catheterization in the postoperative patient.
Obstet Gynecol 2000;95:S30.
9. Cuaresma A, Habana A, Early removal of urinary catheter in cesarean delivery in a
tertiary training hospital. For publication.
10. National Collaborating Centre for Women's and Children's Health. Caesarean section.
London (UK): National Institute for Clinical Excellence (NICE); 2004 Apr.
 PEDIATRIC ATTENDANCE AT CESAREAN SECTION

A. Recommendations

Cesarean sections (CS) with regional anesthesia or those without suspicion of

fetal compromise (e.g. elective CS of pregnancies at term) require the same level
of resuscitation skills as (non-forceps) vaginal deliveries.1-4 (Level II-2, Grade B)

CS under general anesthesia or performed for fetal indications should be attended

by pediatricians or other practitioners with advanced skills in neonatal
resuscitation, i.e. intubation and positive pressure ventilation.1,3,5,6 (Level II-2,
Grade B)

All skilled birth attendants should have training in neonatal resuscitation.7

(Level III, Grade C)

B. Supporting Evidence

1. Pediatric Attendance at CS with Regional Anesthesia

Data from 44,938 eligible deliveries extracted from a prospectively collected,

hospital-based cohort study (from 1990 to 2002) on term (> 37 weeks) singleton infants
revealed no significant difference in need for resuscitation between infants born by
elective CS under regional anesthetic compared with spontaneous vaginal delivery
(chi2=0.998; df=1; P=.318). The authors concluded that the presence of a practitioner
with advanced resuscitation skills is not required at elective CS under regional anesthesia
provided there are no additional risk factors.1
One large population-based cohort study analyzed data from the Tasmanian
Obstetric and Neonatal Audit database on 31, 820 singleton deliveries born at > 37 weeks
gestation over the 6-year period from January 1998 to December 2003 inclusive. Of
these, 21,733 (68.3%) were spontaneous unassisted vertex vaginal deliveries and 2,918
(9.2%) were elective CS performed under regional anesthesia (2,620 spinal and 298
epidural). The incidence of low Apgar scores after elective CS were significantly lower
when compared to unassisted, spontaneous, vertex vaginal delivery i.e. for a 1-minute
Apgar score of < 4 (RR 0.36, 95% CI 0.21-0.60, p < 0.05) and a 1-minute Apgar score of
4 to < 7 (RR 0.73, 95% CI 0.65-0.81, p < 0.05). The authors concluded that elective CS
performed under regional anaesthesia are low-risk deliveries and as such do not require
the routine attendance of experienced paediatric medical staff.2
Levine et.al. analyzed a database of 17,867 consecutive deliveries and found no
significantly increased risk for low Apgar scores (1-minute Apgar < 4) in the group of CS
using regional anesthesia for nonfetal indications (33 of 2057, 1.6% compared to 115 of
 10,270, 1.1% of vaginal deliveries). They concluded that there is no convincing need for
pediatrician attendance at such deliveries.3
One cohort study reported of infants delivered by CS (using regional anesthesia)
were more likely to have a 1-minute Apgar of < 4 (6.3%) compared with infants
delivered vaginally (1.3%.) (RR 3.04 95% CI 1.80-5.13).4

2. Pediatric Attendance at CS for Fetal Indications or Under General Anesthesia

In the previously cited data from 44,938 deliveries in the prospectively collected,
hospital-based cohort study (from 1990 to 2002) on term (> 37 weeks) singleton infants,
general anesthesia, fetal distress, and noncephalic presentation increased the need for
resuscitation.1
In the previously cited study by Levine et. al., (n=17,867 consecutive deliveries)
35 (5.8%) of 596 CS for fetal heart rate abnormality or using general anesthesia had 1-
minute Apgar under 4 in contrast to 115 of 10,270 (1.1%) of vaginal deliveries.3
A large observational study from the USA (n=3,940) reported that infants born
by CS with general anesthesia are at an increased risk of having 1- and 5-minute Apgar
scores of < 7 when compared with those born by CS with regional anesthesia (1-minute
Apgar < 7 RR 3.13, 95% CI 2.5-3.88; 5-minute Apgar RR 3.6, 95% CI 1.81-7.00) and the
need for resuscitation (RR 2.02, 95% CI 1.39-2.9).5
Earlier studies also reported the higher risk of vigorous resuscitation after CS
under general anaesthesia.6

Recommendations of Various Groups

The Royal College of Obstetricians and Gynaecologists (RCOG) (United Kingdom,

2004) state that an appropriately trained practitioner skilled in the resuscitation of the
newborn should be present at CS performed under general anesthesia or where there is
evidence of fetal compromise.7

The Royal Australasian College of Physicians (2004) recommends that:

1. An appropriately-trained practitioner, in addition to the obstetrician and the anaesthetist,
whose responsibility is to administer appropriate resuscitation to the newborn, should be
present at all births by CS.
2. Health care facilities must ensure that staff attending births have adequate and
appropriate training in newborn resuscitation.
3. A practitioner with advanced skills in neonatal resuscitation, including intubation, should
attend all medium and high risk births.
4. There should be appropriate communication between obstetrician and pediatrician on
matters of risk analysis and procedure planning to achieve optimal neonatal outcome.
5. The obstetrician must take responsibility for categorization of risk on each separate
caesarean delivery and plan accordingly.
6. An elective CS with no maternal or fetal risk factors is a low risk birth and requires the
same care as any other low risk birth. There is no evidence that a pediatrician/trainee
pediatrician/other junior medical staff member is required to attend an elective CS where
there are no identified maternal or fetal complicating factors that would predict the need
for vigorous resuscitation.
C. References

1. Gordon A, McKechnie EJ, Jeffery H. Pediatric presence at cesarean section: justified or

not? Am J Obstet Gynecol 2005;193(3 Pt 1):599-605.
2. Atherton N, Parsons SJ, Mansfield P. Attendance of paediatricians at elective caesarean
sections performed under regional anaesthesia: is it warranted? J Paediatr and Child
Health. 2006; 42(6):332-6.
3. Levine EM, Ghai V, Barton JJ, Strom CM. Pediatrician attendance at cesarean delivery:
necessary or not? Obstet Gynecol 1999;93:338-340.
4. Annibale DJ, Hulsey TC, Wagner CL, Southgate WM. Comparative neonatal morbidity
of abdominal and vaginal deliveries after uncomplicated pregnancies. Archives Pediatr
Adolesc Med 1995;149:862867.
5. Ong BY, Cohen MM, Palahniuk RJ. Anesthesia for cesarean sectioneffects on neonates.
Anesth Analg 1989;68:2705.
6. Ng PC, Wong MY, Nelson EAS. Paediatrician attendance at cesarian section. European
Journal of Paediatrics. 1995; 154:672-5.
7. Royal Australasian College of Physicians - Health Policy Unit. Paediatric Policy:
Paediatrician Attendance At Caesarean Sections. Reviewed September 2004
 EARLY SKIN-TO-SKIN CONTACT AND BREASTFEEDING AFTER
CESAREAN SECTION

A. Recommendation

Newborns delivered via cesarean section (CS) (as with all newborns), should be
placed preferably skin-to-skin with the mother as soon as possible (if baby and
mother are deemed stable). They should be given the opportunity to latch on in
the recovery room within one hour after birth or as soon as possible, if latching on
in the operating room was not performed.1-7 (Level 1A, Grade A)

B. Supporting Evidence

Laboratory evidence points to oxytocin and prolactin pulsatility patterns being different
in vaginally delivered (n=20) versus abdominally delivered mothers (n=17) with the former
having significantly more pulses than the CS ones. Mode of delivery and infant's age at first
breastfeed were the most important, independent variables showing a relation to the release
pattern of oxytocin on day 2.1
A 9 month follow-up of 7,825 mother-infant pairs in Hongkong (where breastfeeding
rate was about 30%) showed that cesarean delivery was a risk factor for not initiating
breastfeeding, for breastfeeding less than 1 month, and remained a significant hazard against
breast-feeding duration.2
CS was likewise reported to significantly delay initiation of breastfeeding in a
prospective follow-up of 203 primiparous women in Australia, but this did not impact
significantly on continuation of breastfeeding at 8 months.3
Data from the Mexican Demographic and Health Survey (1987), CS was a risk factor
for non-initiation of breastfeeding (OR 0.64 95% CI 0.50-0.82), and for short breastfeeding
duration (OR 0.58 95% CI 0.37-0.91), but, once lactation was established, was not correlated
with breastfeeding duration (OR 0.97, 95% CI 086-1.11).4
Despite these challenges to breastfeeding, practices can be modified to lessen the
adverse impact of mother-infant separation on breastfeeding. If the newborn is latched on
within two hours after delivery, long-term lactation success was not affected by the cesarean
delivery, even up to six months.5
Early skin-to-skin contact begins ideally at birth and involves placing the naked baby,
covered across the back with a warm blanket, prone on the mother's bare chest. In a
systematic review of 30 studies (n=1925 mother-infant dyads), Moore and co-workers
reported statistically significant and positive effects of early skin-to-skin contact on
breastfeeding at 1 to 4 months of age (10 trials; 552 participants) (OR 1.82, 95% CI 1.08-
3.07), and breastfeeding duration (7 trials; 324 participants) (weighted mean difference
(WMD) 42.55, 95% CI -1.69 to 86.79). Late preterm infants had better cardiorespiratory
stability with early skin-to-skin contact (1 trial; 35 participants) (WMD 2.88, 95% CI 0.53-
5.23). No adverse effects were found. The authors concluded that, despite methodologic
limitations, skin-to-skin contact may benefit breastfeeding outcomes, early mother-infant
 attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-
term negative effects.6
In a prospective cohort of 393 women who delivered term, singleton, babies in
cephalic presentation via forceps or cesarean delivery in the second stage of labor, women
who had a longer in-patient stay (with additional lactation support) after CS were more likely
to achieve exclusive breastfeeding at hospital discharge (78% vs 66%, p = 0.03).7

Recommendations of Various Groups

The World Health Organizations Step 4 in its Ten Successful Steps to Successful
Breastfeeding emphasizes that health personnel should help mothers initiate breastfeeding
within a half-hour after birth.8
The Royal College of Obstetricians and Gynaecologists (RCOG) (United Kingdom,
2004) states that (1) Early skin-to-skin contact between the woman and her baby should be
encouraged and facilitated because it improves maternal perceptions of their infant,
mothering skills, maternal behavior, breastfeeding outcomes, and reduces infant crying, and
(2) Women who have had a CS should be offered additional support to help them to start
breastfeeding as soon possible after the birth of their baby. This is because women who have
had a CS are less likely to start breastfeeding in the first few hours after the birth, but, when
breastfeeding is established, they are as likely to continue as women who have a vaginal
birth.9
The Academy of Breastfeeding Medicine states that Infants are to be put to the breast
as soon after birth as feasible for both mother and infant (within an hour after birth). This is
to be instituted in either the delivery room or recovery room, and every mother is to be
instructed in proper breastfeeding technique. Women need help to ensure that they are able to
position and attach their babies at the breast. Those delivered by CS may need additional
help from nursing staff to attain comfortable positioning.10
The American College of Obstetrics and Gynecology (ACOG) (USA, 2007) states that
(1) The immediate postpartum period should allow the woman and her newborn to
experience optimal bonding with immediate physical contact, preferably skin to skin. The
initial feeding should occur as soon after birth as possible, preferably in the first hour when
the baby is awake, alert, and ready to suckle. (2) Although abdominal delivery may make
breastfeeding more challenging, these mothers should still be encouraged to breastfeed.11

C. References

1. Nissen E, Uvnas-Moberg K, Svensson K, Stock S, Widstrom AM, Winberg J. Different

patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women
delivered by caesarean section or by the vaginal route. Early Human Development. 1996;
45(1-2):103-18.
2. Leung GM, Lam T-H, Ho L-M. Breast-feeding and its relation to smoking and mode of
delivery. Obstetrics and Gynecology 2002; 99:78594.
3. Rowe-Murray HJ, Fisher JR. Baby friendly hospital practices: cesarean section is a
persistent barrier to early initiation of breastfeeding. Birth. 2002; 29(2):124-31.
4. Perez-Escamilla R, Maulen-Radovan I, Dewey KG. The association between cesarian
delivery and breast-feeding outcomes among Mexican women. American Journal of
Public Health 1996; 86:832-836.
5. Vestermark V, Hogdall CK, Birch M, Plenov G, Toftager-Larsen K. Influence of the
mode of delivery on initiation of breast-feeding. European Journal of Obstetrics and
Gynecology and Reproductive Biology 1990;38:338.
6. Moore E, Anderson G, Bergman N. Early skin-to-skin contact for mothers and their
healthy newborn infants. Cochrane Database of Systematic Reviews
2007;18(3):CD003519.
7. Patel RR, Liebling RE, Murphy DJ.Effect of operative delivery in the second stage of
labor on breastfeeding success. Birth 2003; 30(4):255-60.
8. WHO. Division of Child Health and Development. Evidence for the ten steps to
successful breastfeeding. 1998. Geneva.
9. National Collaborating Centre for Women's and Children's Health. Caesarean section.
London (UK): National Institute for Clinical Excellence (NICE); 2004 Apr.
10. The Academy of Breastfeeding Medicine. ABM Protocol #5: Peripartum breastfeeding
management for the healthy mother and infant at term. Available at:
http://www.bfmed.org/ace-files/protocol/peripartum.pdf
11. American College of Obstetrics and Gynecology. Committee on Health Care for
Underserved Women and the Committee on Obstetric Practice. Special Report of the
ACOG. Breastfeeding: Maternal and Infant Aspects. ACOG Clinical Review. 12 (1)
Supplement. Jan-Feb 2007.
 MATERNAL FEEDING AFTER CESAREAN SECTION

A. Recommendation

There is no evidence to recommend a policy of delaying oral fluids and food after
cesarean section (CS). Postpartum women who are recovering well after an
uncomplicated CS can be allowed to eat or drink when they feel hungry or
thirsty.1, 6-11 (Level I, Grade A)

B. Supporting Evidence

It is customarily practiced by obstetricians that patients who undergo CS are not

allowed to eat or drink until bowel function has returned, as substantiated by the presence of
normoactive bowel sounds or passage of flatus. The validity of the routine practice of
withholding anything by mouth to patients after CS has been disputed because since the
bowels are not usually exposed or handled during the surgery, bowel function is therefore not
disrupted.1
Some authorities believe that the gastrointestinal function immediately returns after
abdominal surgery. Antagonists of this view argue, however, that there is a high risk of
complications from giving oral fluids or food after surgery. Authors offer varied alternatives
of feeding after a CS. Bennett, et. al. recommend that after bowel sounds are heard, there
should be a gradual introduction of fluids, followed by light diet. Handling of the bowels
during CS will put the woman at risk of developing paralytic ileus if food is introduced too
early.2 Sellers, et. al. recommend a 12 to 24-hour wait prior to the introduction of fluids.3
Only when fluids are well tolerated, bowel sounds are heard and flatus has been passed,
should regular diet be commenced. Gabbe, et. al. advocate giving oral fluids the day after
surgery despite diminished bowel sounds and absence of flatus, for as long as there has been
no extensive bowel manipulation during the surgery.4 Knuppel, et. al. follow a graded
introduction of clear liquids initially, followed by general liquids, thereafter a regular diet can
be started.5 Kramer, et. al. suggested that the onset of bowel function and the development of
paralytic ileus is influenced by a number of variables other than early feeding, including the
type of surgery performed, neural and hormonal factors, involvement of the sympathetic and
parasympathetic nervous system, use of narcotics and type of anesthetic used. Paralytic ileus
is described as decreased or absence of intestinal peristalsis following abdominal surgery
associated with abdominal tenderness and distension, absence of bowel sounds, absence of
flatus, and nausea and vomiting.6
A systematic review compared early with delayed oral fluids and food after CS.7 Six
randomized controlled trials (RCT) were included. Three RCTs1,8,9 were limited to CS under
regional anesthesia, while the rest included both regional analgesia and general
anesthesia.6,10,11 The comparison groups varied. For instance, in the early feeding group, one
study allowed fluids only1, one allowed a slush diet11 and others allowed both solids and
liquids. This group allowed either immediate access to solids or liquids within 6-8 hours after
CS or as soon as the woman is hungry or thirsty. The delayed feeding group either used a
minimum of 12-24 hours, or to the presence of bowel sounds and graduated intake.
 Early feeding after CS is associated with the following:
1. Reduced time to return of bowel sounds (1 study, 118 women; RR -4.30 hours, 95% CI -
6.78 to -1.82)
2. Reduced postoperative hospital stay following surgery under regional analgesia (2 RCTs,
220 women; RR -0.75 days, 95% CI -1.37 to -0.12; random effects model). There was
significant heterogeneity in this assessment, thus a random effects model was used for
this analysis.
3. A trend to reduced abdominal distension (3 studies, 369 women; RR 0.78, 95% CI 0.55-
1.11).
There were no significant differences in terms of the following: postoperative nausea,
time to bowel action, time to passing flatus, paralytic ileus, and number of analgesics used
postoperatively.
Withholding of food and fluids after CS has no significant benefit to a patient who
has just undergone CS. There is currently no evidence to support the routine practice of
delaying oral food and fluids after CS, especially since some of these patients have not had
any food during labor. There is some evidence, albeit not strong, that early food and drink
speeds bowel recovery. Due to the limited number of studies available for analysis of
individual outcomes, data should be interpreted with caution.

C. References

1. Guedj P, Eldor J, Stark M. Immediate post operative oral rehydration after caesarean
section. Asia-Oceania Journal of Obstetrics and Gynaecology 1991;17(2):125-9.
2. Bennett VR, Brown LK. Myles textbook for midwives 13th edition. Toronto: Churchill
Livingstone 1999
3. Sellers PM. Midwifery. Vol. 2, Kenwyn: Juta & co. Ltd, 1993.
4. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: normal and problem pregnancies. 3rd
Edition. New York: Churchill Livingstone, 1996.
5. Knuppel RA, Drukker JE. High risk pregnancy: a team approach. 2nd Edition. London:
WB Saunders Company, 1993.
6. Kramer RL, Van Someren JK, Qualls CR, Curet LB. Postoperative management of
cesarean patients: the effect of immediate feeding on the incidence of ileus. Obstetrics
and Gynecology 1996; 88:29-32.
7. Mangesi L, Hofmeyr GJ. Early compared with delayed oral fluids and food after
caesarean section. Cochrane Database of Systematic Reviews 2007 Issue 3.
8. Burrows WR, Gingo AJ, Rose SM, Zwick SI, Kosty DL, Dierker LJ, et al. Safety and
efficacy of early post operative solid food consumption after caesarean section. Journal
of Reproductive Medicine 1995; 40:463-7.
9. Patolia DS, Hilliard RLM, Toy EC, Baker B. Early feeding after cesarean: randomized
trial. Obstetrics and Gynecology 2001; 98(1):113-6.
10. Pruitt B, Brumfield C, Owen J, Savage K, Cliver S. Early feeding after cesarean: a
randomized clinical trial [abstract]. Obstetrics and Gynecology 2000; 95(4 Suppl):64S.
11. Weinstein L, Dyne PL, Duerbeck NB. The PROEF diet - a new postoperative regimen for
oral early feeding. American Journal of Obstetrics and Gynecology 1993; 168:128-31.
 WOUND CARE / GAUZE AND DRESSINGS

A. Recommendations

Remove the dressing 24 hours after the cesarean section (CS). (Level III, Grade
C)

Monitor the patient for fever. (Level III, Grade C)

Assess the wound for signs of infection (such as increasing pain, redness or
discharge) and separation or dehiscence. (Level III, Grade C)

Gently clean and dry the wound daily. (Level III, Grade C)

If needed, plan the removal of sutures or clips. (Level III, Grade C)

Combination of antibiotic ointment Polysporin is preferred for routine

postoperative wound care. (Level III, Grade C)

Encourage the woman to wear loose, comfortable clothes and cotton underwear.
(Level III, Grade C)

Currently, there appears to be no clear evidence or recommendation regarding

which type of dressing, dry gauze versus transparent polyurethane dressings
(Tegaderm), is more appropriate for CS. (Level III, Grade C)

B. Supportive Evidence

The CS incision site is traditionally dressed with dry gauze and tape. However,
transparent polyurethane dressings like Tegaderm are used more recently due to the following
advantages: (1) breathable film allows moisture vapor and oxygen exchange, (2) sterile and
waterproof dressing provides an effective barrier to microorganisms, (3) visibility of the
wound site, (4) allows the patient to shower. Aside from the cost, a major disadvantage is the
limited absorptive capacity of Tegaderm making it more suitable to wounds with only light to
moderate amounts of exudate.
In an effort to identify whether a systematic review or any clinical trial already
existed on the most appropriate type of surgical dressing for CS, the Cochrane Database of
Systematic Reviews, Reproductive Health Library, PubMed, and National Guideline
Clearinghouse were searched. There was no study about this topic which specifically focused
on CS. There was a Cochrane review regarding the choice of dressings for central venous
catheter. The authors conclusion was that there is a high level of uncertainty regarding the
 risk of infection with the central venous catheter dressings identified in the review and further
research is necessary. Other studies mentioned that polyurethane semipermeable film
dressings should be used in preference to traditional mesh gauze dressings in the management
of soft tissue skin graft donor sites.
The decision of which type of dressing is the most appropriate for CS has yet to be
tested rigorously in randomized controlled clinical trials.

C. References

1. Cesarean Section (Clinical Guideline No. 13). National Institute for Health and Clinical
Excellence. (www.nice.org.uk) April 2004.
2. Cho CY, Lo JS. Dressing the Part. Dermatology Clinics. 1998; 16 (1): 25-47.
3. Gillies D, O'Riordan L, Carr D, Frost J, Gunning R, O'Brien I. Gauze and tape and
transparent polyurethane dressings for central venous catheters. Cochrane Database of
Systematic Reviews 2003, Issue 3.
4. Wound Care - Management of skin graft donor sites from the Best Practice Information
Sheet produced by The Joanna Briggs Institute. World of Irish Nursing 2003; 11(4).
 LENGTH OF HOSPITAL STAY

A. Recommendation

No evidence of adverse outcomes associated with early postnatal discharge (three

to four days). (Level I, Grade A)

B. Supporting Evidence

A meta-analysis reviewing the effect of early postnatal discharge versus usual care
from the hospital for healthy mothers and term infants showed that there is no significant
differences in infant readmission: readmission occurring within 3-8 weeks postpartum (RR
1.23, 95% CI 0.37-4.07), maternal readmission with 3-6 weeks postpartum (RR 0.76, 95%
CI 0.17-3.37) and proportion of women breastfeeding at 6 months postpartum (RR 0.70, 95%
CI 0.47-1.03).

C. Reference

Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for
healthy mothers and term infants. Cochraine Database of Systematic Reviews 2007, Issue 3.
 SEXUAL INTERCOURSE AFTER CESAREAN SECTION

A. Recommendation

Sexual intercourse after cesarean section (CS) may be resumed as early as two
weeks postpartum for as long as the patient feels comfortable. However, the
earlier the resumption of sexual activity, the greater the likelihood of
dyspareunia.1 (Level I, Grade A)

B. Supporting Evidence

There were one randomized control trial (RCT)1 and 4 cohort studies that assessed
sexual function after birth. The outcome measures used in the evaluation of postpartum
sexual function are recommencement of sexual activity after birth1,2 and dyspareunia
following birth.1,3,4 At 3 months following birth, there was no significant difference between
those who underwent vaginal delivery and those who underwent CS in terms of: (1) reporting
not having sex since birth (RR 1.12, 95% CI 0.89-1.42) and (2) having pain during sex on the
most recent occasion (RR 1.03, 95% CI 0.91-1.16). 1
A study on the delivery method and self-reported postpartum general health status
among primiparous women (n=971) detected no difference between women who delivered
vaginally (whether assisted or spontaneous) and those who delivered abdominally by CS in
terms of the two outcomes mentioned.5 Another cohort study with a smaller sample size
(n=66) also did not detect any difference in dyspareunia at 2-8 weeks postpartum between the
two groups of women. 4 The study of Hogberg reported that one month postpartum, more
women who underwent CS were more likely to have resumed sexual intercourse compared
with those who delivered vaginally.2 There was also more dyspareunia in the first 3 months
postpartum among women who delivered vaginally. However at six months, there was
already no difference detected in the incidence of dyspareunia between the two groups.3

C. References

1. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, et al. Outcomes
at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at
term: The international randomized Term Breech Trial. JAMA 2002; 287:182231.
2. Hogberg U, Sandstrom A, Nilsson NG. Reproductive patterns among Swedish women
born 19361960. Acta Obstet Gynecol Scand 1992; 71:20714.
3. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Womens sexual health
after childbirth. British Journal of Obstetrics and Gynecology 2000; 107:18695.
4. Goetsch MF. Postpartum dyspareunia. An unexplored problem. Journal of Reproductive
Medicine 1999;44:9638.
5. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum
general health status among primiparous women. Paediatr Perinat Epidemiol
2001;15:23240.
 APPENDIX

LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION

LEVEL DEFINITION
I Evidence obtained from at least one properly randomized controlled trial
Evidence obtained from well-designed controlled trials without
II-1
randomization
Evidence obtained from well-designed cohort or case-control analytic
II-2
studies, preferably from more than one center or research group
Evidence obtained from multiple time series with or without the
II-3
intervention.
Opinions of respected authorities, based on clinical experience; descriptive
III
studies and case reports or reports of expert committees.

GRADE DEFINITION
There is good evidence to support the recommendation of the practice in
A
abnormal uterine bleeding.
There is fair evidence to support the recommendation of the practice in
B
abnormal uterine bleeding.
There is insufficient evidence to recommend for or against the inclusion of
C
the practice in abnormal uterine bleeding.
There is fair evidence to support the recommendation that the practice be
D
excluded in abnormal uterine bleeding.
There is good evidence to support the recommendation that the practice be
E
excluded in abnormal uterine bleeding.
A good practice point (GPP) is a recommendation for best practice based
GPP
on the experience of the Technical Working Group.