What are the steps in the delivery of the fetus during cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Answer

Two important aspects of the delivery are (1) the incision to delivery time (especially in previously compromised fetuses) and (2) delivery of the impacted fetal head. Longer incision to delivery times are associated with worsening neonatal outcomes. [88] The impacted fetal head can be delivered either through pushing the head up from the vagina and elevating it up through the incision or by pulling it up as if it were a breech delivery. This may require extending the incision to make room to maneuver. [89]

After the fetus is delivered, the umbilical cord is doubly clamped and cut. Blood is obtained from the cord for fetal blood typing, and a segment of cord is placed aside for obtaining blood gas results if a concern exists regarding fetal status.

After delivery, oxytocin (20 U) is placed in the intravenous (IV) fluid to increase contractions of the uterus. Carbetocin, an oxytocin derivative currently not available for commercial use in the United States, can also be used. It exerts its effect via the same molecular mechanisms as oxytocin, has a longer half-life, and has been reported to decrease the use of additional oxytocics. Clinical trials comparing the contractile effect of carbetocin and oxytocin reported similar hemodynamic effects and adverse symptoms with both drugs. These include transient hypotension and tachycardia. [90] The placenta is usually delivered manually. Awaiting spontaneous delivery of the placenta with gentle traction is more time consuming but is associated with decreased blood loss, lower risk of endometritis, and lower maternal exposure to fetal red blood cells, which can be important to Rh-negative mothers delivering an Rh-positive fetus. [91, 92]

If the surgery is prolonged, a second dose of antibiotic can be administered every 2 hours to maintain adequate serum concentrations. If the patient has chorioamnionitis, broader-spectrum antibiotics, such as gentamicin and clindamycin or a penicillin with a beta-lactamase inhibitor (eg, piperacillin-tazobactam), are indicated and should be continued in the postoperative period until the patient is afebrile. If methicillin-resistant Staphylococcus epidermidis (MRSA) is suspected as a pathogen, especially in abdominal wall infections, vancomycin will have to be added.


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