Caesarean Section
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
A caesarean plan should state its indication and urgency, the anaesthetic and haemorrhage plan, and postoperative priorities.
Assessment & interpretation
- Confirm presentation when it affects the indication, review placental location and anticipate operative complexity.
Decisions that change management
- NICE advises against routine planned caesarean birth before 39 weeks without an earlier clinical indication.
- Use an urgency category to support communication; provide appropriate pre-incision antimicrobial prophylaxis and thromboprophylaxis assessment.
Follow-up & safety-netting
- Review recovery, pain control, wound symptoms, mobility and the next-pregnancy discussion.
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit for the planned operation or for any urgent maternal/fetal indication. Haemorrhage, sepsis, instability or organ-support needs require increased monitoring/critical care.
When clinic, day care or home care may be suitable
- A caesarean operation requires a maternity surgical setting; antenatal planning may be outpatient until the admission date if no complication requires earlier care.
Before going home
- Afebrile and recovering well, with no unresolved operative/anaesthetic complication, concerning bleeding or respiratory issue; pain is controlled on an oral plan and oral intake/mobility are adequate.
- The urinary catheter has been removed with satisfactory bladder assessment, or a named catheter/voiding-trial plan is provided. Wound, VTE risk and maternal/newborn discharge needs are reviewed.
- NICE UK offers discharge after 24 hours only for selected uncomplicated recovery with home follow-up. This is not an automatic Indian postoperative discharge time; use local service policy and individual surgical readiness.
Discharge medicines and treatment changes
- Use a defined oral analgesic plan: paracetamol plus ibuprofen if suitable, reducing/stopping as pain improves. Avoid codeine/co-codamol while breastfeeding.
- Review the indication, dose and stop date for VTE prophylaxis; teach injections when prescribed. Antibiotic prophylaxis at surgery does not automatically justify a take-home antibiotic course.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Baseline oral pain relief when prescribed.
- Indication: Short-term maternal postoperative/postpartum pain or other mild pain after assessment; adult ≥50 kg
- MSF oral monograph: no pregnancy or breastfeeding contraindication. The dose does not replace assessment of the cause of pain.
- Pain and functional recovery; investigate increasing pain, fever or other warning symptoms.
- Check all prescribed/OTC paracetamol, weight and hepatic risk; suspected excess dosing requires urgent assessment.
Combine only when the clinician has excluded contraindications.
- Indication: Short-term pain relief after birth or gynaecological surgery when NSAIDs are appropriate; not an antenatal regimen
- Short-term use is compatible with breastfeeding in the MSF reference. Do not prescribe while bleeding or renal contraindications remain unresolved.
- Pain response, hydration/urine output, GI pain or bleeding; review renal function when clinically indicated.
- Check current bleeding, renal/hepatic function, allergy/asthma history, anticoagulants and interacting medicines before prescribing.
Tests, pending results and their reviewer
- Arrange repeat CBC/other tests after major blood loss or abnormal findings and identify who acts on the result. Assign pathology review when tissue was sent.
Home care and counselling
- Explain wound hygiene, suture/clip removal if applicable, bladder/bowel care, progressive activity, feeding and contraception. Resume driving/heavy activity when recovered and able to perform safely, with local/insurance requirements met.
- Offer a debrief after an emergency operation and record the uterine incision, complications and implications for future pregnancy.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before discharge | Provide the wound/suture or catheter appointment if required, prescription stop dates and contact details. |
Early home/postnatal contact and week 6 | Assess wound, bleeding, pain, mobility, feeding and emotional recovery; bring forward review for complications. |
Return urgently
- Fever, wound redness/discharge/opening, worsening abdominal pain, heavy bleeding, urinary retention, dyspnoea/chest pain or leg swelling requires urgent review.
- If a prescribed opioid causes maternal excessive sedation or the baby becomes drowsy, breathless or feeds poorly, seek urgent advice.
Open the complete discharge checklist →
Treatment
① Immediate stabilization — first minutes
Cat-1 workflow: declare -> run -> anaesthetic choice by anaesthetist (GA if minutes count/coagulopathy/unstable).
③ First-line treatment & drug regimens
- Surgical prophylaxis, not treatment of established infection
- For a severe beta-lactam allergy, the cited prophylaxis standard uses clindamycin 900 mg IV PLUS gentamicin 5 mg/kg IV as a single pre-incision regimen. Confirm dosing weight/renal risk.
- Allergy history, time relative to incision, operation duration and blood loss
- Prevention of PPH after birth, distinct from treatment or labour augmentation
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
Definitive treatment
- Evidence-favoured technique: Joel-Cohen/transverse suprapubic skin incision; blunt abdominal entry; single-layer uterine closure (selective double-layer); routine peritoneal closure omitted; subcutaneous suture if fat >2 cm; subcuticular skin
- Placental delivery: controlled cord traction + uterotonic (no vigorous manual extraction)
- Impacted head aids: elevation device/vacuum or push-from-below; J/T extensions for preterm segments
- Counts correct -> close -> TAP block/local infiltration analgesia
Monitoring
| Postop | Schedule |
|---|---|
Obs | q30min x2, hourly x4, then q4h day 0-1 |
Urine | Catheter 12-24 h; retention check after removal |
Analgesia | Multimodal: paracetamol 1 g q6h + NSAID if safe + morphine PCA/spinal morphine; TAP blocks reduce opioids |
Wound | 24-h review |
VTE | Enoxaparin 40 mg SC daily from day 1 (neuraxial timing rules respected) |
ERAS | Fluids 1 h post-regional; food when tolerated; mobilise ~6 h |
Treatment failure
- Fever >38 after day 1 -> endometritis/wound workup: swabs, cultures, empiric ampicillin+gentamicin+metronidazole (or ceftriaxone+metronidazole) until afebrile 48 h
Procedure / surgery
Full operative page linked (procedures-caesarean). Accreta encountered -> pas-spectrum intraoperative rules.
Escalation
- HDU/ICU: massive transfusion/sepsis/respiratory compromise
- Necrotising wound infection -> surgical team same-day
⑮ Complications & their management
PPH
PPH module pathways
Endometritis/wound infection
Antibiotics; open/drain collections
Bladder/ureteric injury
Urology repair; stents; cystogram/urogram
VTE
vte module; extended prophylaxis high-risk
Future-praevia/accreta risk
Counsel at discharge; targeted scans next pregnancy
Post-treatment care
- Breastfeeding support immediately
- Discharge day 2-3 uncomplicated
- Next-pregnancy VBAC discussion
- Contraception (LARC possible at CS)
Diagnosis & assessment
- Category-1 declaration = simultaneous theatre prep
- Anticipated difficult CS: obesity, multiple scars, praevia/accreta, transverse lie
Definition: Birth via laparotomy+hysterotomy. Urgency Cat1 immediate maternal/fetal threat (30-min target), Cat2 compromise not immediate (75-min target), Cat3 planned early, Cat4 elective.
Initial assessment
- Indication documented + urgency class assigned
- Consent incl. bladder/ureteric/bowel injury, hysterectomy, transfusion, thrombosis, future-placenta risks
- Pre-op: CBC, group&save (crossmatch praevia/scars), coags if indicated, diabetes plan, antacid prophylaxis + sodium citrate at trolley
- Two IV lines; stockings; VTE assessment; neonatal team alert <37 wks/emergency
Investigations
| Test | Looking for |
|---|---|
Group & save minimum | Transfusion readiness |
Coags if PET/HELLP/DIC suspicion | Regional safety |
Principles & follow-up
Management principles
Sources (11)
2023-09-29 · updated 2026-06-09 · checked 2026-08-23 · verified-live
Open source ↗
NICE overview + Update information page (dates above confirmed)
2025-10 · checked 2026-10-17 · verified-summary
Open source ↗
Targeted recheck: WHO 2025 recognition/treatment trigger (≥500 mL or ≥300 mL with abnormal haemodynamics), concurrent first-response bundle and refractory-haemorrhage fibrinogen target ≥2 g/L if replacing a level <2 g/L. Primary recommendation chapter/table indexed at https://www.ncbi.nlm.nih.gov/bo…
31 March 2021 · updated 10 June 2025 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for lscs, vbac-tolac. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharge…
· checked 2026-10-17 · verified-live
Open source ↗
Adult cefazolin 2 g, 3 g at weight ≥120 kg, four-hour redosing and caesarean severe-beta-lactam-allergy alternative clindamycin plus gentamicin. 2013 standard; formulation preparation separately cross-checked against the cefazolin product label.
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary oral monograph read: adult 1 g 3–4 times daily, maximum 4 g/day, ≥50 kg adult table, 500 mg tablets, duration according to response, hepatic caution and pregnancy/breastfeeding. Pain chapter also checked for 6–8-hour interval. Smaller adults require an individual weight-based prescripti…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary monograph read: pain 200–400 mg, maximum 1200 mg/day; postoperative every 8 hours, maximum 8 days; meals/formulations, renal/GI/bleeding/dehydration/infection contraindications and interactions, short-term breastfeeding. New card restricted to postpartum/nonpregnant care; OHSS renal cau…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.