Transformative trials in cesarean delivery: Antibiotic prophylaxis, tranexamic acid, and uterine closure

Cesarean delivery (CD), performed in nearly one in three U.S. births, is the most common surgical procedure. As utilization has increased, advances in surgical technique and perioperative management, guided by landmark trials, have refined the procedure and improved outcomes. Some of the most significant trials have focused on antibiotic prophylaxis, prevention of postpartum hemorrhage, and standardization of surgical techniques. For example, pre-incision prophylactic cefazolin has reduced the risk of postoperative infectious morbidity up to 60% compared to administration at the time of cord clamping. Additionally, the introduction of TXA to the treatment of obstetric hemorrhage has been shown to reduce maternal mortality related to hemorrhage. Future research should prioritize continuing reduction of maternal morbidity as CD still incurs increased risk of infectious and bleeding morbidity. Another important focus in the era of increased CD rates is research into the optimal closure of the hysterotomy. Identification of patients at risk of uterine rupture in future pregnancies can improve the safety of trial of labor after cesarean delivery (TOLAC); further investigation into how hysterotomy closure may contribute to the development of placenta accreta spectrum can significantly decrease maternal morbidity from an increasingly common and life-threatening placental disorder.