Singleton pregnancy, delivery by cesarean section: clinical guidelines

List of Abbreviations

Terms and Definitions

Antibiotic prophylaxis – preoperative administration of antibacterial drugs to reduce the risk of postoperative wound infection.

Antibacterial therapy – use of antibacterial drugs in the presence of clinical signs of infection to eliminate the pathogen from affected organs and tissues.

Uterine exteriorization – bringing the uterus out of the abdominal cavity to suture the incision.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Cesarean section (CS) is a method of delivery in which the birth of a child occurs via surgical intervention with incision of the pregnant uterus wall, extraction of the fetus and placenta, followed by restoration of uterine integrity.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Not applicable.

1.3 Epidemiology of the Disease or Condition

In the modern world, CS is the most frequent type of operative delivery, and the upward trend in its frequency continues. Among developed countries, the highest rate of CS is observed in the Latin America and Caribbean region (40.5%), followed by North America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%), and Africa (7.3%). Based on data from 121 countries, trend analysis showed that between 1990 and 2014, the global average CS rate increased by 12.4% (from 6.7% to 19.1%) with an average annual growth rate of 4.4% [1]. In the Russian Federation, the frequency of CS was 29.2% in 2017 and 30.1% in 2018 [2].

1.4 Features of Coding the Disease or Condition

O32.0 – Unstable lie of fetus requiring medical care to mother

O32.4 – High head engagement at term requiring medical care to mother

O32.8 – Other forms of malpresentation of fetus requiring medical care to mother

O34.0 – Congenital malformation of uterus requiring medical care to mother

O34.4 – Other abnormalities of cervix requiring medical care to mother

O82 – Single delivery by cesarean section

O82.0 – Delivery by elective cesarean section

O82.1 – Delivery by emergency cesarean section

O82.2 – Delivery by cesarean section with hysterectomy

O82.8 – Other single delivery by cesarean section

O82.9 – Delivery by cesarean section, unspecified

1.5 Classification of the disease or condition

Classification of CS urgency

Category I – emergency – in case of immediate threat to the life of the woman or fetus (should be performed as quickly as possible, but no later than 30 minutes from diagnosis to operative delivery while the patient is in the hospital) [3–6].

Category II – urgent – without obvious signs of life threat, in the presence of maternal or fetal complications that require urgent delivery [6–8].

Category III – scheduled – the time of delivery is determined in accordance with the optimal time of delivery for the woman and fetus [6–8].

1.6 Clinical presentation of the disease or condition

Not applicable.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria are not applicable since Cesarean section is a method of delivery, not a disease.

Recommendations apply to all patients prior to delivery via CS unless otherwise specified.

2.1 Complaints and Anamnesis

Taking complaints and medical history is carried out in accordance with the clinical guidelines "Normal Pregnancy" [9].

2.2 Physical Examination

Comments: This examination should be performed upon admission, as well as before delivery to clarify the obstetric situation and decide on the method of delivery.

Comments: This examination should be performed upon admission and before delivery to clarify the obstetrical situation and determine the method of delivery.

2.3 Laboratory Diagnostics

Comment: Hemoglobin level determination is necessary to detect and treat anemia, which helps reduce the risk of adverse perinatal outcomes [12, 13]. The normal hemoglobin level in the 2nd-3rd trimester is ≥105 g/L [16]. A moderately elevated leukocyte count after CS in the absence of clinical symptoms of purulent-inflammatory complications has a low predictive value for confirming the presence of infection.

Comment: This test is performed due to the possible need for blood transfusion in the event of bleeding.

Comment: If an infection is detected before scheduled hospitalization, the patient should be referred to the Center for Prevention and Control of AIDS and Infectious Diseases to confirm/rule out the diagnosis. If an infection is detected, the newborn undergoes postnatal prophylaxis of vertical transmission [19, 21].

Comment: If an infection is detected before scheduled hospitalization, the patient should be referred for a consultation with a dermatologist-venereologist to confirm/rule out the diagnosis.

Comments: If an infection is detected, the patient should be referred for a consultation with an infectious disease specialist to confirm/rule out the diagnosis. If an infection is detected, the newborn undergoes postnatal prophylaxis of viral transmission [26, 27]. There is no evidence that elective CS reduces the risk of vertical transmission of the infection to the newborn, so it is not recommended without other indications [11]. The transmission of hepatitis B can be reduced by administering immunoglobulin and vaccination to the newborn [28].

Comment: If an infection is detected before scheduled hospitalization, the pregnant woman should be referred for a consultation with an infectious disease specialist to confirm/rule out the diagnosis. There is no evidence that elective CS reduces the risk of vertical transmission of the infection to the newborn, so it is not recommended without other indications [11].

Comments: Screening for group B Streptococcus carriage and subsequent therapy during pregnancy leads to a reduction in maternal birth canal colonization by Streptococcus and the birth of children with signs of intrauterine infection. If the test result is positive, patients are prescribed antibiotic prophylaxis during labor [32].

2.4 Instrumental Diagnostics

Comment: Fetal ultrasound is performed to determine the likelihood of placental localization in the uterine incision area during CS in cases of placenta previa and low-lying placenta along the anterior wall, as well as to diagnose vasa previa, large uterine myoma in the lower uterine segment, fetal dimensions, and certain fetal developmental anomalies (gastrochisis, omphalocele, large sacrococcygeal teratoma, etc.).

Comments: When evaluating the uterine scar and anterior abdominal wall areas, infiltrates should not be visualized. If pathological formations are present, their size and localization must be clearly described. If hyperechoic formations are present in the scar area, information regarding the use of hemostatic sponges during surgery must be obtained. When evaluating the parametrium, the presence or absence of mass lesions (including retroperitoneal localization) and hematomas should be assessed. Retained placental tissue should not be visualized in the uterine cavity [34, 36, 37]. Retained placental tissue is defined as a rounded, hyperechoic formation of spongy structure with vascularization zones; remnants of desquamating decidual tissue may be visualized as a normal variant.

2.5 Other Procedures

• Before CS, it is recommended to consult an anesthesiologist-resuscitator to determine the anesthetic and surgical risk [10, 11].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: The main goal of the anesthesiologist-resuscitator consultation is to examine the patient, record their physical status [38], choose the anesthesia method, and assess the risk of difficult tracheal intubation, thromboembolic complications, aspiration syndrome, and anaphylaxis.

• In the presence of somatic diseases, it is recommended to consult other specialists and undergo additional preoperative examination [10].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Determination of indications for delivery via Cesarean section

• Electively (urgency category III), delivery via CS is recommended in cases of placenta previa and placenta accreta spectrum disorders [39–41].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: These indications are absolute and supported by many national associations of obstetricians and gynecologists, despite the recommendation validity level / evidence level (RVL/EL) C5 assigned due to the impossibility of conducting randomized clinical trials for ethical reasons. In cases of partial placenta previa located 2 cm or less from the internal os, delivery is most frequently performed via CS, though vaginal delivery may be possible depending on parity, readiness of the birth canal (presence or absence of bleeding, and phase of labor).

• Electively (urgency category III), delivery via CS is recommended in cases of vasa previa [42].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: These indications are absolute and supported by many national associations of obstetricians and gynecologists, despite the RVL/EL C5 assigned due to the impossibility of conducting randomized clinical trials for ethical reasons [42].

• Electively (urgency category III), delivery via CS is recommended in the presence of the following previous uterine surgeries: two or more previous CS; myomectomy (FIGO types 2–5 or unknown myomatous node location) [6, 42–45].

For two or more CS, the recommendation validity level is A (evidence level – 2).

For myomectomy, the recommendation validity level is A (evidence level – 3).

Comment: In the presence of a single uterine scar and the patient's categorical refusal of vaginal delivery, delivery via CS is possible.

• Electively (urgency category III), delivery via CS is recommended in the case of a history of hysterotomy (uterine perforation, excision of the tubal cornua, excision of a rudimentary uterine horn, previous classical CS, T-shaped or J-shaped incision) or in the presence of mechanical obstacles from the birth canal to childbirth (anatomically narrow pelvis of grade II or higher; pelvic bone deformation; large uterine myoma, especially in the lower segment, obstructing vaginal delivery; cicatricial deformations of the cervix and vagina following previous surgeries, including after grade III-IV perineal tears; cervical cancer, except for preinvasive and microinvasive forms of cervical cancer) [46–48].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

• Elective delivery (urgency category III) by caesarean section is recommended in suspected macrosomia (≥ 4500 g) [49–51].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

• Elective delivery (urgency category III) by caesarean section is recommended in breech presentation: at a gestational age of less than 32 weeks, in combination with other indications for caesarean section, uterine scar after previous caesarean section, footling breech presentation, estimated fetal weight <2500 g or >3600 g [52–58].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comment: The delivery of a fetus <2500 g or > 3600 g in breech presentation does not constitute a violation of clinical guidelines. Surgical delivery of women with breech presentation is advisory in nature and depends on parity and the obstetric situation.

• Elective delivery (urgency category III) by caesarean section is recommended in persistent transverse lie [6].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comment: In some cases, external cephalic version may be performed at 37 weeks of gestation. If the attempt is unsuccessful, a repeat attempt may be performed at 39⁰–39⁶ weeks or before elective surgery. If external cephalic version is successful at this gestational age, preinduction or induction of labour is necessary because unstable fetal position carries an increased risk of umbilical cord prolapse [59–61].

• Elective delivery (urgency category III) by caesarean section is recommended in a history of shoulder dystocia with an adverse outcome (stillbirth, severe hypoxia, encephalopathy, injury to the infant and mother (pubic symphysis)) [46, 62–65].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comment: Elective caesarean section is performed to prevent recurrent shoulder dystocia if there is a history of shoulder dystocia with an adverse outcome, provided that the estimated fetal weight in the current pregnancy is equal to or greater than in the previous pregnancy. In the event of intraantral fetal death or postnatal disability of the child in previous deliveries and the patient's categorical refusal of vaginal delivery, caesarean section may be considered.

• Elective delivery (urgency category III) by caesarean section is recommended in HIV infection with a viral load before labour >1000 copies/ml, unknown viral load before labour, or non-use of antiretroviral therapy during pregnancy and/or failure to administer antiretroviral prophylaxis during labour [69, 70].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Elective caesarean section for the prevention of mother-to-child transmission of HIV is recommended upon reaching 38 weeks of gestation in the absence of signs of labour.

• Elective delivery (urgency category III) by caesarean section is recommended for certain fetal developmental anomalies (gastroschisis, omphalocele, large sacrococcygeal teratoma) [6, 71].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

Comments: In these cases, delivery by caesarean section is required for a gentler, non-traumatic treatment of the fetus. For small and medium-sized omphaloceles where the liver is not part of the embryonic hernia sac, as well as for small sacrococcygeal teratomas, vaginal delivery may be considered.

• Elective delivery (urgency category III) by caesarean section is recommended for somatic diseases requiring the avoidance of pushing (decompensated cardiovascular diseases, complicated myopia, transplanted kidney) [71].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: In some cases, the decision should be made by a multidisciplinary team involving related specialists.

• Urgent delivery (urgency category II) by caesarean section is recommended in premature rupture of membranes at term with indications for elective caesarean section [6].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Urgent delivery (urgency category II) by caesarean section is recommended in severe pre-eclampsia or HELLP syndrome during pregnancy and labour (in the absence of conditions for rapid vaginal delivery) [72].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Urgent delivery (urgency category II) by caesarean section is recommended for uncorrectable uterine contractility disorders (uterine inertia, uterine dyscoordination, cervical dystocia) not accompanied by fetal distress [73].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Urgent delivery (urgency category II) by caesarean section is recommended when labour induction with oxytocin** is ineffective [74].

GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).

• Urgent delivery (urgency category II) by caesarean section is recommended in chorioamnionitis when the birth canal is unripe for labour [75].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Urgent delivery (urgency category II) by caesarean section is recommended for fetal distress syndrome accompanied by a suspicious CTG pattern that progresses despite therapy (humidified #oxygen and/or rapid administration of fluid and electrolyte balance-affecting solutions, and/or repositioning, and/or acute tocolysis (hexoprenaline**) can be used) or impaired umbilical artery blood flow according to Doppler studies [76].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended for any type of placenta previa with bleeding [41].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended in progressive placental abruption of normally implanted placenta [6].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended in threatened, progressing, or complete uterine rupture [6].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended for fetal distress syndrome accompanied by signs of progressive metabolic acidosis according to CTG or lactate levels [76].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended in cephalopelvic disproportion [6].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended in umbilical cord prolapse or fetal limb prolapse in cephalic presentation [6].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended during an eclamptic seizure in labour [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Emergency delivery (urgency category I) by caesarean section is recommended in maternal agony or sudden death when a live fetus is present (if feasible) [6, 11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: In all emergency delivery cases with full dilation and a low-standing presenting part in the pelvic cavity, the mode of delivery is decided individually based on the clinical situation.

• Delivery by caesarean section is not recommended for fetal anomalies incompatible with life (except for those anomalies that may lead to cephalopelvic disproportion, and situations where vaginal delivery carries a higher risk than caesarean section) [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Delivery by caesarean section is not recommended in intrauterine fetal death (except for situations where vaginal delivery carries a higher risk than caesarean section) [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Delivery by caesarean section is not recommended at a gestational age of <24⁰ weeks in the presence of fetal indications (except for situations where vaginal delivery carries a higher risk than caesarean section) [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Written informed consent from the patient is required due to the unfavourable prognosis for the newborn's life and health.

• Elective delivery by caesarean section is recommended at 39–40 weeks of gestation [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The risk of respiratory disorders is higher in infants born by caesarean section before the onset of labour, but it decreases significantly after 39 weeks of gestation. When certain indications are combined, the timing of delivery may be modified according to the clinical situation [77].

3.2. Surgical technique of Cesarean section delivery

• Prior to delivery by caesarean section, hair removal in the area of the proposed skin incision is recommended [78].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: The procedure should preferably be performed on the day of surgery. Depilatory cream or shaving may be used.

• Prior to CD delivery in the operating room, it is recommended to check fetal position, presentation, and fetal heart rate [79].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Specifics of fetal position and presentation may affect the technical aspects of CD delivery. The absence of a fetal heartbeat in the operating room may alter the mode of delivery.

• In the operating room, placement of an intravenous catheter is recommended for intravenous infusions to ensure timely correction of potential complications [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Prior to CD delivery, infusion therapy with solutions affecting water and electrolyte balance is recommended [8, 82, 83].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

• Prior to CD delivery, antiretroviral prophylaxis for HIV is recommended in infected women who have not received antiretroviral therapy [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Preoperative skin preparation with an alcoholic chlorhexidine solution** is preferred over povidone-iodine** solution for the prevention of surgical site infection in CD [89, 90].

• A transverse skin incision is recommended for CD due to lower postoperative pain and better cosmetic results [91].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: The skin incision may be vertical (midline or paramedian) or transverse in the lower abdomen. The Joel–Cohen laparotomy reduces the average operating time by 11.4 minutes, the time from incision to delivery by 1.9 minutes, lowers the incidence of postoperative fever and hospital stay duration, and reduces postoperative analgesic requirements [91–98].

• During CD, the use of a separate scalpel for the skin incision and deeper tissues is not recommended as it does not reduce the rate of wound infection [92, 95, 99, 100].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2).

• During CD, bladder displacement is not recommended [101, 102].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: Bladder displacement during CD can lead to adhesions with the uterine surgical wound and impaired physiological mobility, subsequently leading to stress urinary incontinence [103].

• A transverse incision in the lower uterine segment is recommended for CD due to its better healing [91, 92].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

• Other types of routine uterine incisions are not recommended for CD (transverse arcuate, low vertical (isthmic-corporal), "classical" (corporal – along the midline of the uterine body), T-shaped or J-shaped incision, fundal transverse incision) [96–98, 104].

GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).

Comments: In subsequent pregnancies and deliveries, patients with a history of CD are at risk of uterine rupture. The highest risk of uterine rupture occurs after "classical" (corporal) and T-shaped incisions (4–9%); lower for vertical (isthmic-corporal) (1–7%) and transverse (0.2–1.5%) incisions. Current guidelines recommend repeat CD for women with a prior classical, J-shaped, or T-anchor uterine incision. When performing a T-anchor, J-shaped, or classical uterine incision, as well as myomectomy during CD, in addition to medical record documentation, surgical log, and discharge summary, the patient must also be informed of the necessity for future deliveries to be performed exclusively via CD. A T-shaped incision heals poorly due to multi-directional wound edges and should therefore be avoided; a J-shaped incision should be performed if necessary [95, 97].

• Blunt extension of the uterine incision in the absence of a scar is recommended during CD due to lower blood loss and reduced need for blood transfusion [95, 97, 98, 101].

GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).

Comment: The incision can be made in the center of the lower uterine segment using a Karr scalpel and then extended laterally with Dörfler scissors or by digital stretching without detaching or displacing the bladder (according to L.A. Gusakov) [10, 102, 105, 106]. It should be remembered that the level of the transverse incision in the lower uterine segment in cephalic presentation should ideally correspond to the projection of the largest diameter of the fetal head to facilitate gentle delivery [10, 105, 107]. In the presence of a uterine scar, sharp extension of the incision is possible; the uterine incision is extended to the left and right with scissors to reduce the risk of the incision extending into a tear of the lower uterine wall and bladder when extracting the fetus.

• When making a transverse uterine incision, it is recommended to spread the wound edges in the cranio-caudal direction [8, 108].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Spreading the edges in the cranio-caudal direction is associated with a lower risk of uncontrolled extension (7.4% vs. 3.7%) and a blood loss volume greater than 1500 ml (2.0% vs. 0.2%) [95, 101]. Transverse spreading of the wound edges is not a violation of recommendations.

• The following surgical technique is recommended for delivering a fetus in cephalic presentation during CD: insert four fingers between the anterior or posterior uterine walls and the fetal head, placing them below its level, then slightly elevate the head and, flexing the fingers, guide it into the incision [109–112].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: In case of difficult fetal delivery, rocking movements and excessive force are not recommended; one should calmly assess the situation and determine the cause of the difficulty. The assistant applies fundal pressure to facilitate delivery of the fetal head. If, despite the assistant's help, the head does not deliver, extending the incision upward (J-shaped incision) is recommended. Anchor incisions on the uterus are currently not recommended because they impair postoperative wound healing conditions [113, 114]. When performing preterm operative delivery, extracting the fetus within an intact amniotic sac is preferred to reduce the risk of trauma to the fetus [109, 112].

• Extraction of a low-lying fetal head during CD is recommended by pushing it upward through the vagina with the assistant's hand [109, 110].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

• Extraction of a low-lying fetal head during CD is recommended by grasping both lower extremities and gently pulling on them to deliver the fetus [111, 112].

GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).

Comments: If, despite the use of the above techniques, difficulties in delivering the fetal head persist, the use of obstetric forceps (sometimes a single blade is sufficient) may be considered [112, 113, 115].

• Extraction of a high-lying fetal head during CD is recommended by internal podalic version followed by breech extraction [116].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2).

• Extraction of a high-lying fetal head during CD is recommended using instruments (obstetric forceps, vacuum extractor) [114, 117].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Delivery of a fetus in transverse lie during CD is recommended by bringing down the lower leg followed by delivery of the trunk and head [113] or by performing a J-shaped or vertical uterine incision.

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• When delivering a fetus in transverse lie with the fetal spine directed toward the pelvic inlet and an intact amniotic sac, it is recommended, prior to making the uterine incision, to perform an intra-abdominal version of the fetus to a cephalic or breech presentation for safe extraction through the lower segment incision [116], or to perform a vertical uterine incision prior to version [117].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Vertical hysterotomy, even if restricted to the lower segment, is less preferable than a transverse incision because it may increase the risk of uterine rupture in a subsequent pregnancy, but it may be necessary if the lower uterine segment is not fully formed. If the fetus is large, especially if the membranes have ruptured and a shoulder has entered the incision, a classical incision may be required [118, 119]. Sometimes difficulties in fetal extraction are the result of inadequate anesthesia, leading to tension in the pregnant woman's abdominal muscles. Appropriate measures to deepen anesthesia are required to resolve this issue.

• In placenta previa and when it is impossible to avoid the placenta lying in the path of the incision, it is recommended to rapidly separate it manually down to the membranes and rupture them [120, 121].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: The likelihood of the placenta being located in the incision area should be determined by ultrasound during the preoperative evaluation. Most commonly, the placenta is detached downward (when the major part of it is located in the body and fundus of the uterus), less often upward or laterally (when the main part is in the lower segment). "Drilling through" and tearing the placenta with the operating surgeon's finger or cutting it with a scalpel inevitably leads to fetal blood loss, making it necessary to clamp the umbilical cord as quickly as possible [10].

• To reduce blood loss, the use of uterotonic therapy after fetal extraction is recommended [122, 123].

GRC ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comment: Uterotonic therapy can be performed using the following medications: oxytocin** 1 ml (5 IU) intravenously slowly (over 1–2 minutes) after birth of the fetus, or intravenously via a syringe pump at a rate of 16.2 ml/hour (27 mIU/min) after birth of the fetus, or via an infusion at a rate of 40 drops/min (5 IU in 500 ml of sodium chloride** solution); carbetocin** 1 ml (100 mcg) intravenously immediately after birth of the fetus, slowly over 1 minute (only in the presence of risk factors for intra- and postoperative bleeding).

Comment: This method of placental delivery is associated with a lower volume of blood loss, lesser drop in hematocrit in the postpartum period, and a reduced incidence of endometritis and length of hospital stay compared to manual removal and separation.

• During cesarean delivery, curettage of the uterine walls is not recommended [124].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

Comment: Removal and excessive trauma to the uterine mucosa can lead to synechia formation and Asherman's syndrome [125].

• During cesarean delivery, exteriorization of the uterus during its repair is recommended at the physician's discretion: the uterus may be exteriorized from the abdominal cavity or remain inside [8, 126].

GCR BLEL 1Grade of Recommendation B (Level of Evidence – 1).

Comments: Exteriorization of the uterus results in mechanical compression and clamping of the uterine vessels, reducing blood loss. It should be noted that the uterus should be brought out into the wound when complete visualization of its posterior surface is necessary (myomectomy, metroplasty for placenta accreta, etc.) [10, 92, 126].

• During cesarean delivery, either a single-layer or double-layer suture is recommended, especially when there are difficulties in approximating the wound edges, increased bleeding, or a high risk of infection [97, 127].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

Comments: Studies comparing single-layer and double-layer sutures, involving nearly 15,000 patients, have shown comparable results regarding overall maternal infectious morbidity, endometritis, and blood transfusion [128]. The use of a single-layer suture is associated with shorter operative time, less tissue trauma, and less foreign suture material left in the wound. These potential benefits may lead to a reduction in operative and postoperative complications [129]. However, large recent randomized trials have shown that the rate of uterine rupture does not differ depending on the uterine suturing technique [98, 119, 129].

• During cesarean delivery, closure of the visceral and parietal peritoneum is recommended at the physician's discretion [8, 119].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comments: Omitting the closure of the visceral and/or parietal peritoneum does not lead to an increase in complications, but is associated with a shorter operative time, reduced analgesic requirements, lower postoperative morbidity, and a shorter postoperative hospital stay. No difference in postoperative adhesion formation was found between peritoneal closure (visceral and parietal) and non-closure [10, 92, 98, 119].

• During cesarean delivery, approximation of the rectus abdominis muscles is recommended at the physician's discretion and is not mandatory [129, 130].

GRC ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: The rectus abdominis muscles should be approximated without tension, as tight approximation can lead to pain. Approximating the rectus muscles provides additional conditions for hemostasis. If the abdominal muscles are not approximated, they return to their natural anatomical position on their own, whereas tight suturing can cause pain and adhesions [95, 131].

• During cesarean delivery, closure of the aponeurosis is recommended using a single-layer suture [132].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

• During cesarean delivery, closure of the subcutaneous tissue is recommended if its thickness is 2 cm or more [10, 92, 133].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Closure of subcutaneous tissue thicker than 2 cm helps reduce the overall rate of abdominal wall wound complications, especially hematomas and wound seromas. This restoration of abdominal wall integrity is combined with a significant reduction in wound dehiscence and seroma formation. When the subcutaneous fat thickness is less than 2 cm, it should not be sutured due to the lack of reduction in wound infection rates [10, 92, 133].

• During cesarean delivery, routine drainage of subcutaneous tissue is not recommended in obese patients (body mass index (BMI) ≥30 kg/m²) [10].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Routine drainage increases operative time and presents additional discomfort for patients without offering any advantages in reducing wound infection [10, 92, 134].

• When restoring skin integrity, any of the following skin closure methods is recommended: interrupted sutures, continuous subcuticular suture, staples [8, 10, 135].

GCR BLEL 1Grade of Recommendation B (Level of Evidence – 1).

Comment: The use of staples is inferior to absorbable suture material. Staples save time during suturing, but their cosmetic outcome is inferior, similar to the use of non-absorbable suture material (if not removed). In general, a cosmetic suture is more convenient for women, although it takes longer to close the skin wound, it significantly lessens suture-related infectious complications [135].

3.3. Anesthetic management of Cesarean section

• Prior to anesthesia, the anesthesiologist-resuscitator is recommended to: take a medical history and perform a focused physical examination [131]; take into account physiological changes in the woman's body during pregnancy, as well as FDA teratogenicity classes of medications and contraindications to their use during pregnancy and breastfeeding [10, 136–141]; document in the medical chart the patient's (or her relatives'/representatives') informed consent/refusal for the proposed anesthetic management, necessary procedures, and intensive care (blood component transfusion, central line catheterization, etc.) [139]; perform an examination and record the patient's physical status [38], risk of difficult tracheal intubation [142], risk of thromboembolic complications, risk of aspiration syndrome, risk of anaphylaxis, and details of preventive measures taken in the labor and delivery record [137, 138, 140].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• Prior to cesarean delivery, the anesthesiologist-resuscitator is recommended to assess the patient's physical status using the ASA score to enhance maternal and fetal safety in the perioperative period [38, 143, 144] (Appendix G1).

GGR BLOC 1Grade of Recommendation B (Level of Evidence – 1).

• During cesarean delivery, it is recommended to complete checklists for the following patient safety measures: equipment and medication check; preoperative patient assessment and preparation; syringe labeling; difficult/failed tracheal intubation (Appendices G2, A3.4); anaphylaxis; local anesthetic systemic toxicity; massive hemorrhage; postoperative care, including pain management; sanitary and epidemiological safety [145, 146].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• Prior to cesarean delivery, the anesthesiologist-resuscitator is recommended to check the operability of the anesthesia machine before starting anesthesia [145, 146] (Appendix A3.2).

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: Checking the operability of the anesthesia machine is carried out according to a checklist to improve the safety of the mother and fetus. The equipment of the anesthesiology and intensive care unit of a maternity hospital and perinatal center is regulated by normative documents [145].

• During planned delivery via Cesarean section, it is recommended to carry out prophylaxis of aspiration syndrome (nil-by-mouth policy, antacids, rapid sequence induction) to prevent pulmonary complications [147–149].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Prophylaxis of aspiration syndrome includes [150–156]: surgery with preserved consciousness (neuraxial techniques); interval between food intake and the start of anesthesia: nil-by-mouth policy (for liquids this interval is 2 hours, for solid food 6–8 hours); rapid sequence induction principle. None of the drugs proposed for aspiration syndrome prophylaxis have an evidence base. Sellick's maneuver should be performed at the stage of mask ventilation.

• In uncomplicated pregnancy and planned Cesarean section, it is recommended to intake a moderate volume of clear fluid more than 2 hours before the start of anesthesia [147, 150, 157].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Clear fluids include: water, pulp-free fruit juice, carbonated beverages, tea, black coffee. The volume of fluid is less important than the absence of particles in the fluid. However, patients with additional risk factors for aspiration (e.g., grade 2–3 obesity, diabetes mellitus, difficult airways) or patients with an increased risk of operative delivery (e.g., adverse fetal heart rate profile) may have stricter fluid intake restrictions; the decision should be made individually. Solid food should not be consumed.

• During delivery via Cesarean section, it is recommended to place the patient in a supine position with a left lateral table tilt of up to 30 degrees [99, 100] and adrenergic and dopaminergic agents for the prevention and treatment of hypotension [150, 158–163].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: The use of a lumbar wedge with a left lateral table tilt of more than 15 degrees leads to a reduction in hypotensive complications and a decrease in systolic blood pressure (from -8.80 mmHg to -4.42 mmHg) [99, 100].

• In the perioperative period, recommended are non-invasive monitoring (blood pressure, heart rate, capnometry, ECG, SpO₂), and monitoring of hourly urine output [164].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• During delivery via Cesarean section, recommended are both methods of neuraxial anesthesia (epidural, spinal, combined spinal-epidural) and general anesthesia [137, 165–171].

GCR BLEL 1Grade of Recommendation B (Level of Evidence – 1).

Comments: With the undeniable predominance of neuraxial anesthesia for Cesarean section, general anesthesia can be used when there are contraindications to neuraxial anesthesia [136, 139, 150, 172–175]. In pregnancy, the risk of complications from general anesthesia is significantly higher, and its performance is technically more complex due to a number of reasons. The incidence of difficult intubations in the general population of surgical patients of various profiles is approximately 1 in 2500–3000, whereas in obstetric anesthesia this figure increases to 1 in 250–300 cases, which is almost 10 times higher. In case of failed or prolonged intubation, maternal desaturation occurs much faster than in patients of other groups due to changes in the respiratory system. Mask ventilation may be ineffective and, furthermore, such ventilation predisposes to regurgitation of gastric contents [140].

• After delivery via Cesarean section, it is recommended to transport the patient either to the intensive care unit (within the structure of the anesthesiology and resuscitation department) or to the post-anesthesia care unit, where she should stay until complete recovery (consciousness, breathing, muscle tone, hemodynamics, diuresis) after the administered anesthesia [150, 175–178].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• During delivery via Cesarean section, it is recommended to choose epidural anesthesia over spinal anesthesia in clinical situations where changes in intracranial pressure or systemic blood pressure are undesirable, or when prolonged postoperative analgesia is planned [137, 141, 150, 169, 175, 178], as well as in cases of prior epidural catheterization during labor [179].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Spinal and epidural anesthesia are equally safe, but spinal anesthesia is more frequently accompanied by arterial hypotension [173, 180]. At the same time, the advantages of spinal anesthesia over epidural anesthesia in Cesarean section include: technical simplicity; faster onset of effect (the latent period fits into the time required for positioning the patient and preparing the surgical field); cost-effectiveness of the method (compared to epidural anesthesia); less pain; a lower dose of local anesthetic, which excludes drug overdose and virtually eliminates the toxic effect of local anesthetics; more complete sensory and motor block. Particular features must be taken into account when administering anesthesia in patients receiving anticoagulants and/or vitamin K antagonists, salicylic acid and its derivatives (Appendix G5). In patients with a high risk of complications, elective catheterization of the epidural space can be performed in the early stages of labor, which will allow timely confirmation of normal catheter function.

• During delivery via Cesarean section, when choosing the anesthesia method, it is recommended to take into account the following patient contraindications to neuraxial anesthesia: patient refusal [136–139]; pronounced hypovolemia (hemorrhagic shock, dehydration) [136–139]; blood coagulation disorders towards hypocoagulation; acquired or congenital coagulopathies [136–139]; purulent formations at the puncture site [136–139]; systemic infections [10, 138, 139, 181]; intolerance to local anesthetics [136–139]; presence of fixed cardiac output in patients with an artificial cardiac pacemaker, aortic valve stenosis, coarctation of the aorta, pronounced mitral valve stenosis [136–139]; severe hepatic impairment [136–139]; demyelinating diseases of the nervous system and peripheral neuropathy; diseases associated with high intracranial pressure [136–139]; tattoo at the puncture site [136, 139, 140, 150].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Spinal anesthesia is not contraindicated in pregnant women with severe preeclampsia [182]. Blood coagulation disorders towards hypocoagulation are determined by the following laboratory parameters: INR >1.5; prolongation of aPTT >1.5 times, fibrinogen <1.0 g/L, thrombocytopenia <70*10⁹/L. With thrombocytopenia from 70 to 100*10⁹/L and in the absence of hypocoagulation, only spinal anesthesia can be used (small needle diameter – 27-29G). Intolerance, as well as anaphylaxis, to amide-type local anesthetics is extremely rare. In patients with cardiac pathology, the feasibility of regional anesthesia is assessed individually and agreed upon with the cardiovascular surgeon. In patients with neurological diseases, the feasibility of regional anesthesia is assessed individually and agreed upon with the neurologist and/or neurosurgeon.

• Performing a lumbar puncture is recommended via either the midline or paramedian approach at the level below L2, since the spinal cord terminates at this level [147].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• During neuraxial anesthesia, it is recommended to use thin (25G and thinner) spinal needles, which also reduces the risk of post-dural puncture headache. For lumbar puncture, it is recommended to use pencil-point spinal needles, which reduce the incidence of post-dural puncture headache [147, 150, 157].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: For spinal anesthesia in Cesarean section, hyperbaric and isobaric solutions of the local anesthetic bupivacaine hydrochloride ATC N01BB01 Bupivacaine are used. The duration of spinal anesthesia is limited, and the absence of a spinal catheter makes it impossible to administer additional doses of the anesthetic. Transition to continuous spinal anesthesia is advisable in case of inadvertent dural puncture during epidural catheterization. The catheter is advanced by 2–2.5 cm into the subarachnoid space and fixed, after which it can be used to administer drugs in appropriate dosages.

• During neuraxial anesthesia in parturients with obesity, it is recommended to use a local anesthetic dose similar to that in parturients without obesity [183].

GPPLE 2Strong Recommendation Grade based on Level 2 Evidence (Grade of recommendation A, Level of evidence – 2).

• When performing Caesarean section and choosing an anesthesia method, it is recommended to consider the following potential complications of neuraxial anesthesia: immediate complications – arterial hypotension; bradycardia, asystole; nausea and vomiting; hypothermia and shivering; high and total spinal block; pruritus (when using opioids); toxic effects of local anesthetics in case of intravascular administration; cardiac arrest during high spinal block due to blockade of cardiac nerves (T1–T4); delayed complications – post-dural puncture headache; post-dural puncture back pain; urinary retention; neurological complications; transient neurological symptoms; cauda equina syndrome; neurological deficit due to needle trauma to the spinal cord, spinal nerves, and epidural venous plexus radicles; infectious complications: post-dural puncture meningitis and meningoencephalitis, epidural and subdural abscesses [150, 175, 184–188].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Hypotension caused by sympathetic blockade leads to decreased uteroplacental blood flow and therefore always requires treatment. Methods for preventing hypotension during spinal anesthesia: adrenergic and dopaminergic agonists (see above), compression stockings, pre-infusion, and co-infusion [182]. As part of the treatment for local anesthetic systemic toxicity, it is recommended to administer a 20% lipid emulsion for parenteral nutrition** intravenously as a bolus of 1.5 ml/kg, followed by an infusion at a rate of 0.25 ml/kg/min for 30–60 minutes depending on the severity of toxic manifestations. The maximum dose of 20% lipid emulsion for parenteral nutrition** is 10 ml/kg [147]. Epidural blood patch may be recommended to relieve headache [189]. To prevent neuraxial infection, it is recommended to insert the epidural catheter under aseptic conditions. The anesthesiologist-resuscitologist must wear a face mask, cap, and sterile gloves. The puncture site must be treated with an antiseptic solution (ATX Antiseptics and disinfectants) [190, 191].

• In case of ineffective epidural anesthesia with signs of residual sensory block, the local anesthetic dose for spinal anesthesia is recommended to be reduced by 30%; if there are no signs of sensory block after failed epidural anesthesia, the dose for spinal anesthesia can be standard [179, 194].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

Comment: Spinal anesthesia following failed epidural anesthesia may be associated with a high (total) spinal block due to compression of the intrathecal space by the epidurally administered solution.

• If paresthesia occurs repeatedly during epidural catheter insertion, it is recommended to remove the catheter and needle and perform a new insertion to prevent nerve root damage [147, 190].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• The use of combined spinal-epidural anesthesia is recommended if the duration of the Caesarean section is expected to exceed the duration of spinal anesthesia [147, 150, 157].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: #Oxygen inhalation during neuraxial anesthesia has neither beneficial nor harmful effects on short-term fetal clinical outcomes [138, 139, 190, 195].

• During Caesarean delivery, general anesthesia is recommended if the patient refuses neuraxial anesthesia or if there are contraindications to neuraxial anesthesia; [136–140, 181, 196]. ⁵⁰

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: General anesthetics cross the placenta, which can lead to neonatal depression.⁵⁰

• Induction of general anesthesia is recommended only after preparation and draping of the surgical field, and in the presence of obstetrician-gynecologists ready to perform the surgery, and a neonatologist (Appendix G6) [197].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: It is necessary to provide prophylaxis against regurgitation and aspiration of gastric contents into the trachea; place the pregnant woman supine and displace the uterus to the left; insert an intravenous catheter; place a urinary catheter; ensure standard monitoring – SpO2, blood pressure, heart rate, ECG, diuresis, capnometry; premedication 30–40 minutes before surgery – #diphenhydramine** (or an equivalent dose of an analogue) – 0.15–0.25 mg/kg intramuscularly (in an emergency, intravenously before induction), atropine** – 0.4–0.6 mg intramuscularly 45–60 minutes before anesthesia; preoxygenation with 100% #oxygen (O₂) for 3 minutes is mandatory (in an emergency, any artificial lung ventilation (ALV) is initiated only after endotracheal intubation).

• During Caesarean delivery under general anesthesia, rapid sequence induction is recommended [10, 138–140, 169, 197, 198].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Drugs used for general anesthesia: sodium thiopental** 4–5 mg/kg intravenously; propofol** may be used at a dose not exceeding 2.5 mg/kg. In case of hemorrhage – #ketamine** (1–1.5 mg/kg) [197]. Muscle relaxation (#suxamethonium chloride** at a dose of 1–1.5 mg/kg) [271], endotracheal intubation using the Sellick maneuver. As soon as the parturient loses consciousness, the assistant begins applying pressure to the cricoid cartilage and continues this until the endotracheal tube is inserted and its correct placement is confirmed using capnography. The "BURP" maneuver (back, upward, right lateral pressure) can be used as an external laryngeal manipulation during difficult intubation to facilitate visualization.

• During general anesthesia before fetal delivery, it is recommended to perform mechanical ventilation in the normoventilation mode, maintaining the end-tidal carbon dioxide concentration at approximately 32 mm Hg [147, 197].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Dinitrogen oxide** and #oxygen are used in a 1:1 ratio or halogenated hydrocarbons up to 1.5 vol %. The use of halogenated hydrocarbons at a concentration below 1 minimum alveolar concentration (MAC) is not accompanied by pronounced uterine atony and hemorrhage, and the risk of intraoperative awareness is practically reduced to zero. Muscle relaxation is maintained with peripheral muscle relaxants [147, 197].

• During general anesthesia after fetal delivery, the concentration of the inhalational anesthetic should be reduced to 0.5 of the minimum alveolar concentration or even less, with the addition of dinitrogen oxide** and the opioid ATC N01AH01 fentanyl** [147, 197].

GRC ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comment: In most cases, intravenous administration of oxytocin** allows suppression of the uterine-relaxing effects of inhalational anesthetics if the concentration is maintained at 0.5 MAC. Opioid analgesics are used only after fetal delivery. General anesthesia increases the risk of postpartum hemorrhage [147, 197].

3.4. Cesarean section in the event of sudden cardiac arrest in a pregnant woman

Comments: Sudden cardiac arrest during pregnancy is a relatively rare complication with an incidence ranging on average from 1:12,000 to 1:30,000 deliveries [201, 202]. The basic principles of basic life support in pregnant women have specific features that must be taken into account. The main causes of sudden cardiac arrest include: postpartum hemorrhage, antepartum hemorrhage, heart disease, anesthesia, amniotic fluid embolism, trauma, sepsis, eclampsia, pulmonary embolism, stroke, acute pulmonary edema, myocardial infarction, aortic dissection [203].

Comments: The gravid uterus impairs venous return due to aortocaval compression, thereby reducing cardiac performance by approximately 60%. Delivery reduces oxygen consumption, improves venous return and cardiac performance, facilitates closed chest compressions, and improves ventilation. It also allows for internal cardiac massage via the diaphragm.

Comment: Basic life support in pregnant women is performed in accordance with the recommendations of the National Resuscitation Council [219] and international guidelines [200, 220, 221].

Comments: Perimortem hysterotomy and delivery are performed in the best interest of both mother and fetus. At a gestational age of up to 20 weeks, emergency Cesarean section may be omitted, as it is unlikely that the pregnant uterus significantly affects cardiac output at this stage. At 20–23 weeks of gestation, emergency perimortem hysterotomy and delivery are performed to save the mother's life, but not the fetus, whereas at more than 24 weeks, emergency perimortem hysterotomy and delivery are performed to save the lives of both mother and fetus. Perimortem hysterotomy and delivery must be considered a resuscitation procedure performed primarily for maternal survival [226–228]. It is recommended to always have an emergency kit for perimortem hysterotomy and delivery ready: a scalpel with a number 10 blade (the only essential instrument); obstetrical forceps; scissors; suture material; needles; Kelly clamps; Balfour retractors. Perimortem hysterotomy and delivery should not be delayed by moving the patient. It must be performed where the maternal cardiac arrest occurred and basic life support is being administered. Performing resuscitation during transport significantly reduces its quality, but if it is absolutely impossible to perform the procedure on site, the fastest possible transport of the woman to an appropriate level of care is permissible. If resuscitation is successful, following delivery, the woman should be transported to the nearest medical facility capable of providing surgical and intensive care. The obstetrician-gynecologist should use the incision that provides the fastest access: this may be a lower midline laparotomy or a suprapubic transverse incision. A scalpel and umbilical cord clamp (or alternative ligatures) must be available at all stages of medical care (including the pre-hospital stage and the intensive care unit). If resuscitation is successful, the uterus and abdominal cavity are closed in the standard manner with blood loss monitoring and prevention of purulent-septic complications.

• Following delivery after sudden cardiac arrest, it is recommended that advanced life support measures (venous access, defibrillation, medications) be performed in accordance with the recommendations of the Russian National Resuscitation Council and the European Resuscitation Council (ERC) for 30 minutes [200, 219–221].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• When performing advanced life support during sudden cardiac arrest in a pregnant woman, it is recommended to use the same defibrillation settings as in non-pregnant patients [203, 229, 230].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

• When performing advanced life support during sudden cardiac arrest in a pregnant woman, it is recommended to use the same medications and venous access as in non-pregnant patients [200, 203, 219–221, 231, 232]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Recommended routes of drug administration during cardiopulmonary resuscitation (which are the safest and ensure effective pharmacokinetics) are intravenous or intraosseous. After administering drugs into a peripheral vein, it should be flushed with at least 20 ml of saline and elevated for 10–20 seconds to accelerate drug delivery to the central circulation. Intraosseous access is used if intravenous access cannot be secured after three attempts. With intraosseous drug administration, adequate plasma concentrations are achieved at approximately the same rate as with intravenous administration.

3.5. Management of postpartum patients after Cesarean section

• Following Cesarean section, it is recommended to provide adequate pain relief, thromboprophylaxis, early enteral nutrition, early mobilization, glucose control, and removal of the urinary catheter [233, 234].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Following Cesarean section, it is recommended to achieve early transfer from the intensive care unit (or recovery room) to the postpartum ward after surgery performed under neuroaxial (spinal, epidural, combined spinal-epidural) anesthesia as well as general anesthesia [11].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Exceptions include patients with preeclampsia, bleeding before and during surgery or in the early postoperative period, severe somatic diseases requiring monitoring of hemodynamics and vital organ function, management by an intensive care specialist, technical difficulties during surgery, or an extended surgical scope (myomectomy, hysterectomy, adhesive disease, etc.).

• Following Cesarean section, it is recommended to remove the urinary catheter after patient mobilization, but no earlier than 2–4 hours after the last dose of local anesthetic is administered into the epidural space [234].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: the earliest possible removal of the urinary catheter minimizes the risk of catheter-associated infection. The catheter should be removed after the regression of the spinal block [234].

• Following Cesarean section, it is recommended to remove the dressing after 6 hours; once the dressing is removed, the patient should take a daily shower, and there is no need for daily antiseptic treatment [11, 235, 236].

GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).

Comment: Early removal of the postoperative wound dressing minimizes the risk of wound infection [235, 236].

• Following Cesarean section, it is recommended to achieve early mobilization of the patient: 4–6 hours after surgery, the woman is assisted to first sit up in bed, dangle her legs, and then gradually begin walking [235].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Early mobilization minimizes the risk of abdominal adhesions, pulmonary congestion (especially likely after general anesthesia), and thromboembolic complications associated with prolonged immobilization [235, 237]. Contraindications to early mobilization include: body temperature above 38°C; lower extremity thrombophlebitis; bleeding; severe pain (visual analogue scale (VAS) >50 mm) (Appendix G7).

• Following Cesarean section, the following methods are recommended for adequate postoperative pain relief: nonsteroidal anti-inflammatory drugs; paracetamol**; wound infiltration with local anesthetic solutions; transversus abdominis plane (TAP) block [176, 238–245].

GCR BLEL 1Grade of Recommendation B (Level of Evidence – 1).

Comments: A multimodal analgesia regimen after Cesarean section is preferred. Since opioid use is associated with known side effects, pain management techniques that reduce or completely replace opioid use should be employed. At the end of surgery or at the beginning of the early postoperative period, IV infusion of paracetamol** at a dose of 1 g is recommended, with a total daily dose not exceeding 4 g/day.

• Following Cesarean section under epidural anesthesia, it is recommended to continue analgesia in the postoperative period via continuous infusion or patient-controlled analgesia [238].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• In case of severe pain (VAS >50 mm), it is recommended to add trimeperidine** up to 20 mg or fentanyl** up to 100 mcg intravenously [238], [246].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

• In case of moderate pain intensity (VAS = 30–50 mm), it is recommended to add tramadol** [238].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Administration of a single perioperative dose of #dexamethasone** at 0.11–0.2 mg/kg is recommended to improve analgesia in patients undergoing surgery under general anesthesia [247, 248].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: This may be associated with higher blood glucose levels 24 hours postoperatively and should be avoided in patients with insulin resistance [247, 248].

• TAP block is recommended for the treatment of postoperative pain in patients who do not respond to routine analgesics and opioids [249–251].

GPPLE 2Strong Recommendation Grade based on Level 2 Evidence (Grade of recommendation A, Level of evidence – 2).

Comment: In patients after general or spinal anesthesia, TAP block can significantly reduce postoperative pain and decrease opioid consumption. TAP block provides analgesia after cesarean section with a mean analgesic effect of 9.5 hours (8.5–11.9 hours). It can be recommended in the postoperative period both in the absence and presence of an epidural catheter [249–251]. Epidural analgesia is a quite effective method of postoperative pain relief, although it does not promote early mobilization of patients due to the preservation of motor block.

• Following delivery via cesarean section under neuroaxial anesthesia, it is recommended to allow fluid intake for the parturient immediately after the end of surgery. Parturients after cesarean section under general anesthesia are allowed fluid intake 2 hours after the end of surgery [252].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Starting from the third hour after surgery, parturients may receive food corresponding to a regular diet, excluding bread, vegetables, and fruits. For parturients who have undergone general anesthesia, enteral nutrition may be prescribed 4–6 hours after surgery (broth); after 24 hours, a regular diet.

• Following delivery via cesarean section, recommended is a documented assessment of risk factors for venous thromboembolism (VTE) in accordance with the clinical guidelines "Venous Complications During Pregnancy and the Postpartum Period. Obstetric Thromboembolism" [253, 254].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Following delivery via cesarean section in the absence of contraindications, the use of elastic compression of the lower extremities is recommended to reduce the risk of VTE [253].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: There are no studies substantiating the use of compression hosiery during pregnancy and the postpartum period, and recommendations are largely derived by extrapolating data from studies investigating the use of compression hosiery in the non-pregnant hospitalized patient population. Small studies have shown that the use of compression hosiery significantly improves venous return in pregnant women and enhances blood flow while simultaneously decreasing the lumen diameter of the superficial and deep femoral veins in patients in the late stages of pregnancy and the early postpartum period [253].

• Following delivery via cesarean section and prior to hospital discharge, it is recommended to perform dynamic monitoring and examination for the early detection of postoperative complications [245].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Examination includes: monitor control for 2 hours (ECG, non-invasive blood pressure measurement, pulse oximetry); assessment of pain intensity using the VAS scale; measurement of blood pressure, pulse, assessment of skin condition; evaluation of bowel peristalsis; external examination to determine the size, consistency, and tenderness of the uterus; assessment of the amount and character of lochia corresponding to the stage of uterine involution; determination of the condition of the mammary glands (absence of nipple fissures with signs of suppuration and lactostasis); assessment of the condition of the postoperative suture (signs of edema, infiltration, dehiscence, bleeding); palpation of the lower extremity veins; assessment of urine output volume. Monitoring can be performed by an anesthetist nurse, midwife, or physician. Monitoring is carried out: immediately after cesarean section; every 20–30 minutes postoperatively for 2 hours; every 2–3 hours from 2 hours postoperatively up to 6 hours; after transfer to the postpartum ward – once daily; upon any patient complaints, hyperthermia, heavy bloody discharge, etc. Body temperature up to 38°C and leukocytosis within 24 hours after delivery (including after cesarean section) are acceptable. The cause is most frequently dehydration; therefore, the management strategy is abundant fluid intake, infusion therapy. The prescription of anti-inflammatory therapy is not indicated. Examination after cesarean section is carried out in accordance with the clinical guidelines "Normal Postpartum Period (Postpartum Care and Examination)" [255].

• Intraoperative early mother-infant skin-to-skin contact is recommended under regional anesthesia methods, in the absence of maternal complications and with a satisfactory condition of the newborn, immediately after drying and swaddling. Early skin-to-skin contact (mother-newborn) as well as rooming-in must be ensured [37, 237].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: It is not recommended to separate the mother and newborn, and whenever possible, they should remain in the same room around the clock [37, 237]. Visits to the child by the father should also be encouraged. This promotes the formation of a healthy relationship between the parents and the newborn, and successful breastfeeding.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

• Prior to delivery via cesarean section, antibiotic prophylaxis is recommended [11, 256–265].

GCR BLEL 1Grade of Recommendation B (Level of Evidence – 1).

Comments: An exception is made for pregnant women at low risk of infection (duration of preoperative hospitalization up to 14 days, absence of clinical and laboratory data indicating an infectious-inflammatory process and other aggravating factors), in whom antibiotic prophylaxis may be omitted [258–266]. From the standpoint of efficacy and safety, the most appropriate drugs for antibiotic prophylaxis are first- and second-generation cephalosporins (cefazolin**, cefuroxime**) and penicillin combinations, including combinations with beta-lactamase inhibitors (amoxicillin + [clavulanic acid]**, ampicillin + [sulbactam]**) [258–260] (Table 1). Informed consent of the patient must be obtained for the administration or refusal of antibiotic prophylaxis. Antibiotic prophylaxis regimen: single administration of the antibacterial drug 30–60 minutes before the start of surgery [262, 263]. In obesity (BMI ≥30 kg/m²), the antibiotic dose should be doubled (cefazolin** up to 2 g) [260, 261, 267]. Prolonged surgery exceeding 2 half-lives of the drug (>4 hours for cefazolin** from the time of the initial dose) requires an additional intraoperative dose of the same antibiotic. Massive blood loss (>1500 mL) also requires an additional intraoperative dose of the same antibiotic. Prolonged postoperative antibiotic administration may be considered in women with BMI ≥35 kg/m² (for 48 hours) [261]. Breastfeeding must be taken into account when choosing an antibiotic [262]. In patients with known colonization by methicillin-resistant S. aureus (MRSA) undergoing cesarean section, a single dose of vancomycin** may be added to the recommended antibiotic prophylaxis regimen. Monoprophylaxis with vancomycin** alone is not recommended.

Table 1. Drugs used for antibiotic prophylaxis [258, 259].

• Prior to delivery via cesarean section, vaginal cleansing is recommended for patients in labor and patients with ruptured membranes to reduce the risk of purulent-inflammatory complications [89].

GPPLE 1Strong Recommendation Grade based on Level 1 Evidence (Grade of recommendation A, Level of evidence – 1).

Comment: For this purpose, chlorhexidine**[266], as well as #povidone-iodine**[266] solution may be used (only medicinal products registered in the Russian Federation whose instructions for use indicate the possibility of #povidone-iodine** use under individual medical supervision, if the benefit to the mother outweighs the risk to the fetus). Vaginal cleansing immediately prior to CS in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Additional data are needed to assess how useful this measure may be in CS in women with intact membranes and who are not in labor [88].

• Following delivery via cesarean section, patients are recommended to receive counseling at discharge regarding the features of the postpartum period, contraception, and subsequent pregnancy planning [37, 242].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The patient is issued a "Cesarean Section Surgery Passport" (Appendix B2). The next pregnancy is recommended no earlier than 12–18 months later, as this is the period for optimal healing of the uterine incision and the formation of a full-fledged scar. This interval increases the likelihood of a successful trial of labor after cesarean and reduces the risk of uterine rupture. Counseling on contraception for planning subsequent pregnancies is carried out in accordance with the clinical guidelines "Normal Postpartum Period (Postpartum Care and Examination)" [255].

• Following delivery by cesarean section, it is recommended to limit lifting weights exceeding the newborn's weight [173, 179, 182].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The restriction on lifting heavy objects for 4–6 weeks is due to the need to reduce tension on the aponeurosis for better healing, rather than to decrease intra-abdominal pressure, changes in which affect pelvic floor muscle function [173, 179, 182]. In the postoperative period, women may gradually increase physical activity depending on the degree of discomfort and the presence of postoperative complications. Physical activity helps improve mood, control weight, promotes weight loss, and reduces anxiety and depression. Pelvic floor muscle strengthening exercises can compensate for urinary incontinence if present [140, 235, 253, 268, 269].

6. Organization of Medical Care

Medical care for women undergoing elective cesarean section is provided in accordance with routing schemes approved by regional healthcare management authorities.

Elective cesarean section is performed in level 2 obstetric hospitals with round-the-clock on-call obstetrician-gynecologists, neonatologists, and anesthesiologists, as well as in level 3 obstetric hospitals. The criteria for referring pregnant women to level 3A obstetric hospitals are diseases and conditions that determine a high degree of risk for the mother and/or fetus, as listed in the Procedure for the Provision of Medical Care in the Profile «Obstetrics and Gynecology» (excluding the use of assisted reproductive technologies). During elective cesarean section, indications are determined by an obstetrician-gynecologist depending on the course of pregnancy, obstetric situation, concomitant somatic diseases, and fetal condition. In clinically complex cases, the choice of delivery method and timing of hospitalization is determined by a medical concilium.

In the event of urgent and emergency indications for cesarean section, the surgery is performed in the hospital where the patient is located at the time of diagnosis, provided that the necessary medical equipment and personnel are available to care for the mother and newborn, or the patient is transferred to a level 2 or level 3 obstetric hospital, provided that transportation is feasible and there are no contraindications from the patient. The transfer of patients with established emergency and urgent indications for cesarean section is carried out by medical transport accompanied by medical personnel.

Discharge of postpartum women from the obstetric hospital after cesarean section is carried out according to general rules under the following conditions:

• absence of hyperthermia (above 37.2°C) and an uncomplicated postoperative course;

• absence of pathological findings on ultrasound of the uterus and appendages;

• absence of signs of mastitis and lactostasis;

• absence of signs of inflammation in the suture area.

Discharge is possible with non-absorbable suture material followed by suture removal at the place of residence.

7. Additional Information

Not applicable.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Roman G. Shmakov – MD, PhD, Professor of the Russian Academy of Sciences, Director of the Academician V.I. Krasnopolsky Moscow Regional Research Institute of Obstetrics and Gynecology, Professor of the Department of Obstetrics and Gynecology named after Academician G.M. Savelieva, Pediatric Faculty, Pirogov Russian National Research University of the Ministry of Health of Russia, Chief Freelance Specialist in Obstetrics of the Ministry of Health of Russia. No conflict of interest.

2. Sergey V. Martirosyan – PhD, Associate Professor at the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow), expert at the National Institute of Quality of Roszdravnadzor. No conflict of interest.

3. Anton V. Mikhailov – Professor, Chief Freelance Specialist in Obstetrics and Gynecology of the Healthcare Committee of St. Petersburg, Chief Physician of St. Petersburg State Budgetary Healthcare Institution «Maternity Hospital No. 17». No conflict of interest.

4. Aleksey V. Pyregov – MD, PhD, Professor, Deputy Chief Physician for Anesthesiology and Reanimatology, Moscow Regional Perinatal Center, Chief Freelance Specialist in Obstetric Anesthesiology and Reanimatology of the Ministry of Health of the Moscow Region. Chairman of the Committee on Anesthesiology and Reanimatology in Obstetrics and Gynecology of the Association of Anesthesiologists-Reanimatologists (Moscow). No conflict of interest.

5. Ildar F. Fatkullin – D.Sc. (Medicine), Professor, Head of the Prof. V.S. Gruздеv Department of Obstetrics and Gynecology, Kazan State Medical University, Chief freelance specialist of the Russian Ministry of Health in obstetrics and gynecology in the Volga Federal District (Kazan). No conflict of interest.

6. Efim M. Shifman – MD, PhD, Professor, Professor of the Department of Anesthesiology and Reanimatology, Faculty of Advanced Medical Training, Moscow Regional Research Clinical Institute named after M.F. Vladimirsky, President of the Association of Obstetric Anesthesiologists-Reanimatologists, Member of the SIVA Presidium, Honored Doctor of the Republic of Karelia, Expert in Anesthesiology and Reanimatology of the Federal Service for Surveillance in Healthcare (Moscow). No conflict of interest.

7. Natalya V. Artymuk – D.Sc. (Medicine), Professor, Head of the Professor G.A. Ushakov Department of Obstetrics and Gynecology, Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelancer Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District (Kemerovo). No conflict of interest.

8. Baev Oleg Radomirovich – MD, PhD, Professor, Honored Doctor of the Russian Federation, Head of the Maternity Ward, Head of the Department of Obstetrics and Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

9. Igor I. Baranov – MD, PhD, Professor, Head of the Department of Scientific and Educational Programs, Department of Scientific Activity Organization, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

10. Bashmakova Nadezhda Vasilievna – D.Sc. in Medicine, Professor, Chief Researcher at the Ural Research Institute for Maternal and Infant Care of the Russian Ministry of Health, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Ural Federal District (Yekaterinburg). No conflict of interest.

11. Bezhenar Vitaly Fedorovich – D.Sc. in Medicine, Professor, Head of the Clinic of Obstetrics and Gynecology, Head of the Department of Obstetrics, Gynecology and Neonatology, Head of the Department of Obstetrics, Gynecology and Reproductology at the Academician I.P. Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Northwestern Federal District (Saint Petersburg). No conflict of interest.

12. Tatyana E. Belokrinitskaya – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Advanced Training and Professional Retraining, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Freelancer Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Far Eastern Federal District (Chita). No conflict of interest.

13. Vagushchenko Ulyana Andreevna – Obstetrician-Gynecologist at the Organizational and Methodological Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

14. Dolgushina Nataliya Vitalievna – D.Sc. (Medicine), Professor, Deputy Director for Research, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Women's Reproductive Health (Moscow). There is no conflict of interest.

15. Zabolotskikh Igor Borisovich – D.Sc. in Medicine, Professor, Head of the Department of Anesthesiology, Intensive Care and Transfusiology at the Faculty of Advanced Training and Professional Retraining of Kuban State Medical University of the Russian Ministry of Health, Head of the Anesthesiology and Intensive Care Service at Regional Clinical Hospital No. 2 of the Ministry of Health of Krasnodar Krai (Krasnodar). Member of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists and Intensivists. No conflict of interest.

16. Kinzhalova Svetlana Vladimirovna – Ph.D. in Medicine, Head of the Department of Anesthesiology and Intensive Care, Ural Research Institute for Maternal and Infant Care of the Russian Ministry of Health. Member of the Association of Obstetric Anesthesiologists and Intensivists (Yekaterinburg). No conflict of interest.

17. Klimov Vladimir Anatolyevich – Ph.D. in Medicine, Head of the Medical Care Organization and Information Service at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

18. Koltasheva Irina Mikhailovna – Head of the Department of Quality Management and Medical Care Safety, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

19. Korostelev Yury Mikhailovich – Ph.D. in Medicine, Associate Professor at the Department of Anesthesiology and Intensive Care, Academician I.P. Pavlov First St. Petersburg State Medical University, Head of the ICU at Maternity Hospital No. 10 (Saint Petersburg), Member of the Committee for Anesthesiology and Intensive Care in Obstetrics and Gynecology of the Association of Obstetric Anesthesiologists and Intensivists. No conflict of interest.

20. Kostin Igor Nikolaevich – D.Sc. in Medicine, Professor at the Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (Moscow). No conflict of interest.

21. Kulikov Alexander Veniaminovich – D.Sc. in Medicine, Professor at the Department of Anesthesiology, Intensive Care and Transfusiology of the Faculty of Advanced Training and Professional Retraining, Ural State Medical University of the Russian Ministry of Health (Yekaterinburg). Member of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists and Intensivists. No conflict of interest.

22. Logutova Lidia Sergeevna – D.Sc. in Medicine, Professor, Leading Researcher at the Department of Research Coordination and Publishing, Moscow Regional Research Institute of Obstetrics and Gynecology (MONIIAG) (Moscow). No conflict of interest.

23. Malyshkina Anna Ivanovna – D.Sc. in Medicine, Professor, Director of the V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Central Federal District (Ivanovo). No conflict of interest.

24. Oboskalova Tatyana Anatolyevna – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology, Ural State Medical University (Yekaterinburg). No conflict of interest.

25. Ovezov Alexey Muradovich – D.Sc. in Medicine, Professor, Head of the Department of Anesthesiology and Intensive Care at the Faculty of Advanced Medical Training, M.F. Vladimirsky Moscow Regional Research Clinical Institute (MONIKI), Chief Anesthesiologist-Intensivist of the Ministry of Health of Moscow Oblast (Moscow). Member of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists and Intensivists. No conflict of interest.

26. Pekarev Oleg Grigorievich – D.Sc. in Medicine, Professor, Deputy Chief Medical Officer, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

27. Natalya A. Pepelyaeva – PhD in Medicine, Head of the Delivery Room, Ural Research Institute of Maternity and Infancy Care of the Russian Ministry of Health (Yekaterinburg). No conflict of interest.

28. Evgenia S. Polushkina – PhD in Medicine, Senior Researcher at the Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation (Moscow). No conflict of interest.

29. Popandopulo Victoria Alexandrovna – D.Sc. in Medicine, Professor, Chief Medical Officer of the Clinic, Vice-Rector for Clinical Work, Kuban State University of the Russian Ministry of Health, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Southern Federal District (Krasnodar). No conflict of interest.

30. Priputnevich Tatyana Valerievna – D.Sc. in Medicine, Head of the Department of Microbiology and Clinical Pharmacology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

31. Prikhodko Andrey Mikhailovich – Associate Professor, D.Sc. in Medicine; Deputy Director for Research at the Institute of Obstetrics, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

32. Protsenko Denis Nikolaevich – Ph.D. in Medicine, Associate Professor at the Department of Anesthesiology and Intensive Care, Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Chief Medical Officer of Moscow City Clinical Hospital No. 1 named after N.I. Pirogov, Chief Specialist in Anesthesiology and Intensive Care of Moscow (Moscow), Member of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists and Intensivists (Moscow). No conflict of interest.

33. Radzinsky Viktor Evseevich – Corresponding Member of the Russian Academy of Sciences, D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (Moscow). No conflict of interest.

34. Romanov Andrey Yuryevich – Ph.D. in Medicine, Head of the Department of Planning and Support of Scientific Projects, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

35. Ronenson Alexander Mikhailovich – Ph.D. in Medicine, Head of the Department of Anesthesiology and Intensive Care, Tver Regional Clinical Perinatal Center named after E.M. Bakunina. Member of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists and Intensivists (Moscow). No conflict of interest.

36. Semenov Yury Alekseevich – Ph.D. in Medicine, Minister of Health of Chelyabinsk Oblast (Chelyabinsk). No conflict of interest.

37. Vladimir N. Serov – Academician of the RAS, D.Sc. (Medicine), Professor, Honored Scientist of the RF, President of the Russian Society of Obstetricians and Gynecologists, Chief Researcher at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

38. Troshin Pavel Vladimirovich – Anesthesiologist-Intensivist, Assistant at the Department of Anesthesiology and Intensive Care, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

39. Filippov, Oleg S. – D.Sc. (Medicine), Professor, Honored Doctor of the RF, Chief Freelance Obstetrician-Gynecologist of the Federal Medical-Biological Agency (FMBA of Russia), Deputy Director, Federal Research and Clinical Center for Children and Adolescents of the FMBA of Russia, Professor of the Department of Obstetrics, Gynecology and Reproductive Medicine, Russian University of Medicine (Moscow). No conflict of interest.

40. Filippovich Gennady Viktorovich – Anesthesiologist-Intensivist, Assistant at the Department of Anesthesiology and Intensive Care, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. obstetrician-gynecologists

2. obstetrician-gynecologist residents

3. anesthesiologists-reanimatologists

4. anesthesiology and intensive care residents

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Appendix A3. Reference Materials

Related Documents

• Collection of the Federal Research Institute for Health Organization and Informatics of the Russian Ministry of Health, "Main indicators of maternal and child health, the activities of the child and maternity welfare services in the Russian Federation", Moscow, 2019.

• Letter of the Chief Non-Staff Anesthesiologist-Intensivist of the Ministry of Health of the Russian Federation dated December 29, 2016, No. 102/OD-MZ/2016

• Order of the Ministry of Health of the Russian Federation No. 919n of November 15, 2012, "On Approval of the Procedure for Providing Medical Care to Adult Patients in the Profile 'Anesthesiology and Intensive Care'."

• Sanitary and Epidemiological Rules 'Prevention of HIV Infection' (Resolution of the Chief State Sanitary Doctor of the Russian Federation of January 11, 2011, No. 1, as amended on July 21, 2016).

• WHO Surgical Safety Checklist Implementation Manual, 2009.

• Evidence-based clinical guidelines 'Physical and Rehabilitation Medicine' by G.N. Ponomarenko, D.V. Kovlen, Saint Petersburg, 2018.

• Clinical Guidelines of the Russian Association of Dermatovenereologists and Cosmetologists on the Management of Patients with Sexually Transmitted Infections and Urogenital Infections. Delovoy Express Publishing House, 2012: 1-112.

• ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia.

• ACOG Committee Opinion Number 712, August 2017: Intrapartum Management of Intraamniotic Infection.

• ACOG committee opinion No. 433: optimal goals for anesthesia care in obstetrics. ACOG Committee on Obstetric Practice.

• ACOG Committee on Practice Bulletins. ACOG practice bulletin: clinical management guidelines for obstetriciangynecologists. No. 82, June 2007. Management of herpes in pregnancy. Obstet Gynecol 2007;109:1489-98

• ACOG Fetal Macrosomia (Replaces Practice Bulletin Number 22, November 2000) (Reaffirmed 2018)

• ACOG Gestational Diabetes Mellitus Practice Bulletin Number 190, February 2018

• ACOG. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles Replaces Practice Bulletin Number 70, December 2005. Reaffirmed 2017

• ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Committee on Practice Bulletins-Obstetrics.

• ACOG The Use and Development of Checklists in Obstetrics and Gynecology Committee on Patient Safety and Quality Improvement Number 680, November 2016

• ACOG committee opinion no. 764: Medically indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 2019

• ACOG committee opinion. Placenta accreta. Number 266, January 2002.

• ACOG Practice Bulletin no. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019

• ASA Committee on Occupational Health Task Force on Infection Control. 2007.

• Association of Anaesthetists of Great Britain and Ireland (AAGBI). Checking anaesthetic equipment 2012: association of anaesthetists of Great Britain and Ireland. 2012.

• Australasian Society For Infectious Diseases.Management of Perinatal Infections Australasian Society For Infectious Diseases. 2014.

• Categorisation of urgency for caesarean section RANZCOG July 2018

• Commissioned by the National Institute for Health and Clinical Excellence «Caesarean section» National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. November 2011

• ACOG Committee Opinion No. 382: Fetal Monitoring Prior to Scheduled Cesarean Delivery. Committee on Obstetric Practice.

• Guidelines for Perinatal Care. 8^th Edition. ACOG&AAP, 2017.

• NICE Caesarean section Clinical guideline Published: 23 November 2011Last updated August 2019

• RCOG. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a.

• RCOG Birth after Previous Caesarean Birth (Green-top Guideline No. 45)

• RCOG. Classification of urgency of caesarean section: a continuum of risk. Good Practice No. 11, April 2010

• RCOG. Management of Genital Herpes in Pregnancy.  October 2014

• RCOG. The Investigation and Management of the Small–for–Gestational–Age Fetus. Green–top Guideline No. 31 2nd Edition. RCOG, 2013

• RCOG. Green top guideline no. 29: The management of third- and fourth-degree perineal tears. June 2015.

• Rasmussen KC, Secher NH, Pedersen T. Effect of perioperative crystalloid or colloid fluid therapy on hemorrhage, coagulation competence, and outcome: A systematic review and stratified meta-analysis. Medicine (Baltimore). 2016 Aug;95(31):e4498.

• The Cochrane Collaboration. Techniques for assisting difficult delivery at caesarean section (Review) 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

• WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

• WHO recommendations: uterotonics for the prevention of postpartum haemorrhage. World Health Organization. 2018;53 p.

• Guidelines for Perinatal Care. 8^th Edition. ACOG&AAP, 2017

• CDC. Sexually transmitted diseases treatment guidelines 2002. Morbidity and Mortality Weekly Report  2002;51:1–80.

• Guidelines for Perinatal Care. 8^th Edition. ACOG&AAP, 2017

• Antenatal Care. Routine care for the Healthy Pregnant Woman. NICE&NCCWCH, RCOG Press 2008.

Appendix A3.1. Cesarean section operation profile

The surgical protocol must consistently and fully describe the course of the surgery, including:

• date, start and end time of the surgery (including duration)

• operating room number

• urgency category of the surgery

• full name of the procedure (e.g., transverse suprapubic laparotomy with excision of an old skin scar; lower segment cesarean section; myomectomy; adhesiolysis)

• main indications for surgery

• type of anesthesia

• surgical technique (type of laparotomy, excision of skin scar, condition of the uterus, uterine incision, characteristics of amniotic fluid, delivery method, placenta delivery method, condition of the uterine cavity, uterine suturing technique including number of layers and peritonealization, findings of the inspection of the uterus and its appendages, technique for restoring the integrity of the abdominal wall)

• sex, Apgar score of the newborn

• suture material used at each stage

• situations requiring expansion of the surgical scope with a brief justification (myomectomy, adhesiolysis, ovarian resection, etc.)

• technical difficulties and specific features (inability to perform adhesiolysis, spontaneous extension of the incision, hemorrhage, etc.)

• blood loss volume

• urine output volume and characteristics

• surgical team roster (surgeon and assistants)

• additional prescriptions (as indicated)

Appendix A3.2. Anesthesia machine checklist prior to anesthesia

Appendix A3.3. Specific considerations for anesthetic management in female patients receiving antithrombotic agents and/or vitamin K antagonists, salicylic acid and its derivatives

Appendix A3.4. Checklist.

Appendix B. Physician Action Algorithms

Appendix B1. Obstetric Cesarean section safety checklist

Appendix B2. Physician's action algorithm

Monitoring of the postpartum patient's condition for 6 hours after surgery

Total blood loss _______mL

Obstetrician-Gynecologist_________

Anesthesiologist_________

Checklist

Postpartum maternal monitoring in the postpartum unit

by an obstetrician-gynecologist

In case of deviation from the norm, follow the action algorithm according to clinical guidelines for the respective nosologies.

Appendix B3. Difficult intubation algorithm

Appendix B4. "Can't ventilate, can't intubate" algorithm

Appendix C. Patient Information

You have been diagnosed with indications for surgical delivery by cesarean section. Cesarean section is a common procedure performed in 25–30% of all deliveries. Usually (in the absence of special indications), cesarean section is performed at 39–40 weeks of gestation.

You will be hospitalized in an obstetric hospital in advance for delivery. If labor begins or membranes rupture before the estimated delivery date, you must immediately call an ambulance for hospitalization in an obstetric hospital.

In the hospital, you will undergo the necessary list of laboratory and instrumental examinations depending on the obstetric situation. For planned hospitalization, you must refrain from eating food for 8 hours and clear liquids for 2 hours prior to the planned delivery. Clear liquids include water, pulp-free fruit juice, carbonated beverages, tea, and coffee.

Before the surgery, you will be consulted by an obstetrician-gynecologist and an anesthesiologist-resuscitologist. You are required to inform the doctors about all known health problems related to your health, heredity, allergic reactions, individual intolerance to medications and food products, as well as tobacco smoking, alcohol abuse, or drug use in the present and past. The anesthesiologist-resuscitologist will select the most suitable type of anesthesia for you during the surgery. Before the surgery, you will need to put compression stockings on your legs for the prevention of thromboembolic complications, which you will wear throughout the entire postoperative period. You must remove hair from the area of the intended incision (perineum, pubis, lower abdomen). Also, before the surgery, you will receive antibiotic prophylaxis to reduce the risk of purulent-inflammatory postoperative complications.

In the operating room, an intravenous catheter and a urinary catheter will be placed for the duration of the surgery and the first hours after it.

You should be aware that various complications may arise during the surgery, which may require additional interventions and transfusions of blood and hematopoietic products.

In the postoperative period, you will be transferred to the intensive care unit for as long as necessary depending on your condition. In the postoperative period, pain management will be continued, and early mobilization will be offered to reduce the risk of postoperative complications: early sitting up in bed and getting up, usually on the 1st postpartum day. Intake of clear liquids is possible immediately after delivery, and eating food is possible a few hours after delivery.

The time of placing the baby to the breast depends on your condition and your baby's condition, but in the absence of contraindications, early initiation of breastfeeding is practiced: during the surgery or immediately after it.

Suture removal is performed in the hospital or after discharge if necessary, as absorbable suture material is used in a number of cases.

After discharge from the hospital, you must follow a prescribed regimen and activity restrictions during the first months: limitation of lifting heavy objects (>5 kg), abstaining from sexual intercourse, and upon its resumption – the use of contraceptive methods recommended by your attending obstetrician-gynecologist, restriction of physical activity. You must visit your attending obstetrician-gynecologist 1–1.5 months after delivery. Planning the next pregnancy, given your uterine scar, is recommended no earlier than 1 year after delivery following a control ultrasound evaluating the condition of the scar.

You should know that a cesarean section is a relatively safe procedure, but complications are possible during the procedure and in the postoperative period:

• Very common – repeat cesarean section in subsequent deliveries (1 case in every 4 surgeries).

• Common – wound pain and abdominal discomfort in the first few months after surgery (9 cases in every 100 surgeries).

• Common – readmission, postpartum infection (5–6 cases per 100 surgeries).

• Common – fetal injuries, for example, skin laceration by a scalpel (2 cases per 100 surgeries).

• Uncommon – re-operation in the postoperative period, admission to the intensive care unit (5–9 cases per 1,000 surgeries).

• Uncommon – uterine rupture in subsequent pregnancy/labor, placenta previa and accreta, hemorrhage (1–8 cases per 1,000 surgeries).

• Rare – thrombotic complications, bladder injury, ureteral injury during surgery (1–5 cases per 1,000 surgeries).

• Very rare – death (1 woman per 12,000 surgeries).

You should also be aware that the presence of a uterine scar may subsequently reduce your fertility (the ability to conceive and bear children). You should also know that after surgical delivery, a decrease in lactation is noted more frequently than after vaginal delivery.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. ASA Physical Status Classification System

Russian title: ASA Physical Status Classification System

Original title: ASA Physical Status Classification System.

Source: American Society of Anesthesiologists

Type: rating scale.

Purpose: assessment of the patient's baseline physical status prior to surgery.

Content and scoring:

Appendix G2. Visual Analogue Scale for pain intensity.

Russian title: Visual analogue scale for pain intensity.

Original title: Visual analogue pain intensity scale.

Source: Scott J, Huskisson EC. Graphic representation of pain. Pain 1976; 2 (2): 175–184.

Type: rating scale.

Purpose: assessment of pain intensity.

Content: