FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

Abstract

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage‐related maternal deaths in many low‐ and middle‐income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence‐based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

The Impact of Platelet-Rich Plasma Application during Cesarean Section on Wound Healing and Postoperative Pain: A Single-Blind Placebo-Controlled Intervention Study

“…Pregnancy-related risk factors for wound complications after CS include emergency CS, rupture of membranes and chorioamnionitis [20,29]. Surgical risk factors are operating time, surgeon experience, type of suture material, type of incision and abdominal wall closure and the use of antibiotics [14,21]. On the other hand, several evidence-based interventions have been shown to reduce the risk of post-cesarean wound complications, e.g., the administration of antibiotics within 60 min prior to skin incision, using chlorhexidine-alcohol for skin antisepsis and suture closure of the subcutaneous layer in women for whom its thickness is greater than 2 cm [21,[33][34][35].…”

“…Surgical risk factors are operating time, surgeon experience, type of suture material, type of incision and abdominal wall closure and the use of antibiotics [14,21]. On the other hand, several evidence-based interventions have been shown to reduce the risk of post-cesarean wound complications, e.g., the administration of antibiotics within 60 min prior to skin incision, using chlorhexidine-alcohol for skin antisepsis and suture closure of the subcutaneous layer in women for whom its thickness is greater than 2 cm [21,[33][34][35]. Temming et al demonstrated that the risk of wound complications was significantly lower in patients who received all the evidence-based interventions during CS in comparison to those who did not (20.3% vs. 28.1%, aRR 0.75, 95% CI 0.58-0.95), but the risk was still high and the authors concluded that there is a need for finding additional interventions that could be able to further reduce this risk [20].…”

“…Simultaneously, evidence-based actions in the peri-operative management of patients submitted to surgery can beneficially modulate their recovery, especially when a patient needs to take care of a newborn child [14]. According to the FIGO good practice recommendations and enhanced recovery after surgery (ERAS) protocols, the current management strategies for wound healing after CS include prophylactic antibiotics within 60 min of CS and prior to skin incision, chlorhexidine-alcohol for skin antisepsis with 3 min of drying time prior to incision, closure of the subcutaneous layer if it is ≥2 cm in depth, and subcuticular skin closure with sutures rather than with staples [20,21]. The available evidence does not support a recommendation for any particular type of wound dressing, and some possible procedures are not recommended during CS, such as routine use of wound drains or rectus muscle reapproximation (because this increases postoperative pain without any benefit) [14,21].…”

“…According to the FIGO good practice recommendations and enhanced recovery after surgery (ERAS) protocols, the current management strategies for wound healing after CS include prophylactic antibiotics within 60 min of CS and prior to skin incision, chlorhexidine-alcohol for skin antisepsis with 3 min of drying time prior to incision, closure of the subcutaneous layer if it is ≥2 cm in depth, and subcuticular skin closure with sutures rather than with staples [20,21]. The available evidence does not support a recommendation for any particular type of wound dressing, and some possible procedures are not recommended during CS, such as routine use of wound drains or rectus muscle reapproximation (because this increases postoperative pain without any benefit) [14,21]. The use of PRP has been evidenced to improve wound healing in different groups of patients; however, there are only a few studies concerning its use during CS.…”