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'Making the Implicit Explicit': The Recommended Steps of a Caesarean Section, a Delphi Study Among South African
Liesl de Waard1, Rozemiek Neline Hannelore Wessels2, Anke Heitkamp3
1Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Parow, South Africa, sun.ac.za.
Obstetrics and Gynecology International
|July 9, 2026
Summary
South African experts identified 66 essential steps for performing caesarean sections (CSs). This standardized list aims to improve training and reduce maternal complications in low-resource settings.
Area of Science:
- Obstetrics and Gynecology
- Surgical Education
- Patient Safety
Background:
- Caesarean section (CS)-associated maternal complications are a concern in low- and middle-income countries like South Africa.
- Lack of standardized training and skill contributes to these complications.
- Current CS performance and teaching practices in South Africa lack standardization.
Purpose of the Study:
- To identify comprehensive, including implicit, steps for performing a caesarean section (CS).
- To establish a standardized list of CS procedures based on expert consensus in South Africa.
Main Methods:
- A modified three-round Delphi survey involving South African obstetric experts.
- Steps were categorized into preoperative, intraoperative, and postoperative phases.
- Consensus was achieved using a seven-point Likert scale and confidence intervals.
Main Results:
- Sixty-six essential steps for CS were identified after three rounds of expert consensus.
- These steps were categorized as essential, substeps, or excluded.
- Preoperative: 9 essential/14 substeps; Intraoperative: 14 essential/15 substeps; Postoperative: 5 essential/9 substeps.
Conclusions:
- The 66-step comprehensive list can guide the standardization of CS procedures and training.
- Standardization may enhance the safety and quality of caesarean sections.
- This is particularly relevant for low- and middle-income settings where junior doctors often perform CSs with limited supervision.
