Cesarean Delivery Basics: Setting Up For Surgery

Written By Medumentary .

Hello and welcome back! Today, we're diving into an important topic: the cesarean delivery, commonly referred to as a C-section. A cesarean delivery is defined as the birth of the fetus through an abdominal incision into the uterus.

Before we begin, I want to highlight a fantastic but often overlooked resource: the ACOG Surgical Curriculum. It provides detailed modules on common obstetric and gynecologic procedures, including the historical relevance, prevalence, preparation, and surgical steps. You can find it by Googling ACOG Surgical Curriculum. Once you’re on the main page, scroll down to select the relevant procedure. Make sure that when you click on the selected procedure, you then go the the “module” tab on the following page to find all the procedure information. This resource was a lifesaver for me during residency, and I highly recommend it! The link will be in the show notes.

Now, let's walk through everything that needs to happen before the first incision in a C-section. As a medical student or intern, this phase can feel unstructured, but understanding the process will help you feel more confident in the OR.

Step 1: Patient Arrival and Anesthesia Preparation

For scheduled C-sections, the patient will either be rolled by wheelchair or walk into the OR and sit on the side of the bed with their legs dangling off the edge.

For unscheduled C-sections (often referred to as coming off the floor from labor and delivery), they may already have an epidural in place. In this case, they are typically brought in on their labor bed and transferred directly onto the OR table in a supine position. The anesthesiologist will then administer additional anesthetic through the epidural catheter.

During this time, the nursing staff and anesthesia team will:

  • Hook up IVs, blood pressure cuffs, and pulse oximeters.

  • Provide a pillow or Mayo stand for the patient to lean on.

  • Administer neuraxial anesthesia (typically a spinal or combined spinal-epidural).

How You Can Help:

  • Offer the patient warm blankets.

  • Hold their hand and provide reassurance.

  • Help maintain their position while the anesthesia team works.

Once anesthesia is administered, assist the patient into a supine position and ask the anesthesiologist to airplane the bed 15° to the left to minimize vena cava compression.

Step 2: Fetal Heart Monitoring and Positioning the Patient

  • Ensure fetal heart tones are captured using an external monitor.

  • If the patient has a fetal scalp electrode (FSE) in place, determine when it should be removed.

  • Attach arm boards to secure the patient’s arms comfortably.

  • Position the patient’s legs in a butterfly or frog-leg position for the vaginal prep (if performed) and Foley catheter placement.

Vaginal Prep:

  • The ACOG does not mandate vaginal cleansing before a C-section, but studies suggest it reduces post-op endometritis and fever in laboring patients or those with ruptured membranes.

  • If performed, povidone-iodine or chlorhexidine-based solutions are commonly used.

Foley Catheter Placement:

  • Typically done by nursing staff.

  • Ensure the Foley tube is under the leg and off tension to reduce the risk of urethral injury.

Step 3: Preoperative Antibiotics and Safety Measures

  • Communicate with the anesthesiologist about preoperative antibiotics.

  • Most commonly, a first-generation cephalosporin (cefazolin) is administered, with or without azithromycin.

  • Ensure antibiotics are given before incision for optimal prophylaxis.

Additional safety steps:

  • Electrosurgical Grounding Pad – Place this on the patient’s thigh if monopolar electrosurgery (e.g., Bovie) will be used.

  • Sequential Compression Devices (SCDs) – These must be properly positioned on the calves, plugged in, and turned on to prevent thromboembolism.

  • Leg Straps – Secure the patient’s legs with a strap over the thighs (not knees or shins) to prevent movement during surgery.

Step 4: Abdominal Prep and Draping

  • Sterile Abdominal Cleansing – Use chlorhexidine-alcohol prep (ChloraPrep) or povidone-iodine (Betadine).

    • Chlorhexidine must dry for 3 minutes before draping due to fire risk.

    • Betadine does not require drying time.

  • Assist your co-surgeon or the scrub tech in draping the patient, ensuring the surgical field is properly covered.

Once draped, set up:

  • Suction Tubing & Bovie Cord – Pass these off to be plugged in.

  • Bovie Holder – Secure it to the drape with an Allis clamp to keep it within reach.

Step 5: Final Safety Checks Before Incision

  • Test for adequate anesthesia by pinching the planned incision area with an Allis clamp while the anesthesiologist assesses the patient’s response.

  • If anesthesia is confirmed adequate, invite the patient’s support person into the OR (if applicable).

    • If general anesthesia (GA) is required, most institutions do not allow support persons to be present.

Ready for Incision!

Now that everything is in place, the surgical team is ready to begin the cesarean delivery. In the next post, I’ll cover the step-by-step surgical procedure of a C-section. Stay tuned!

References:

Medumentary .
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