Evidence-based cesarean delivery: preoperative management (part 7).

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Suture Compared With Staples for Skin Closure After Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE: Absorbable suture is the preferred method of cesarean skin closure compared with metal staples, because it decreases wound complications. Two recently published trials in patients with obesity contradict this evidence. The goal of this meta-analysis was to assess whether suture remains the recommended method of cesarean skin closure, regardless of obesity status. DATA SOURCES: MEDLINE through OVID, PubMed, Cochrane Database, and ClinicalTrials.gov were searched from inception until September 24, 2021. METHOD OF STUDY SELECTION: Published randomized controlled trials (RCTs) comparing subcuticular absorbable suture with nonabsorbable metal staples for cesarean skin closure were included. Non-RCTs, RCTs that did not compare staples with suture, and ongoing trials were excluded. Fourteen studies met inclusion criteria. TABULATION, INTEGRATION AND RESULTS: Data were individually abstracted and entered into RevMan. Fixed and random effects models were used. The Cochrane risk-of-bias tool was used to assess each study. The primary outcome, a sensitivity analysis of wound complications (excluding studies at high risk of bias), showed a significant decrease in wound complications when the cesarean skin incision was closed with suture compared with staples (10 studies; 71/1,497 vs 194/1,465; risk ratio [RR] 0.47, 95% CI 0.25-0.87). When all studies were analyzed, there remained a significant decrease in wound complications when the skin was closed with suture (14 studies; 121/1,780 vs 242/1,750; RR 0.59, 95% CI 0.36-0.97). Of the individual wound complications, wound separation was significantly decreased with suture closure compared with staples (11 studies; 55/1,319 vs 129/1,273; RR 0.43, 95% CI 0.32-0.58). In patients with obesity, there remained a significant decrease in wound complications with suture closure of the skin incision compared with staples (five studies; 34/507 vs 67/522; RR 0.51, 95% CI 0.34-0.75). CONCLUSION: Closure of the cesarean skin incision with suture decreased composite wound complications by 50% as compared with closure with staples; a significant decrease persisted regardless of obesity status. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021270378.