Background and aims

In low- and middle-income countries, including South Africa, caesarean section (CS)-associated maternal complications, some of which are attributed to lack of skill and training, are of concern. The performing and teaching of CSs are not standardised in South Africa. This study aimed to identify the comprehensive steps, including those that are implicit, of a CS, according to South African experts.

Methods

A modified three-round Delphi survey method was used. The steps were divided into preoperative, intraoperative and postoperative. Invitations were sent to South African obstetric experts for voluntary participation. The aimed sample size was 15, and consensus was reached according to the confidence intervals (CIs) calculated from the Likert scale results. For the first two rounds, a seven-point Likert scale was used. In round three, only steps that had not reached consensus yet were presented to the panel as essential, substeps or excluded.

Results

Invitations were sent to 44 experts: 28 (64%) completed round one, 20 (45%) round two and 19 (43%) round three. Sixty-six steps were identified after three rounds: 9 essential/14 substeps preoperatively, 14 essential/15 substeps intraoperatively and 5 essential/9 substeps postoperatively.

Conclusion

South African obstetric experts recommended 66 steps for performing a CS. This comprehensive list could contribute to the standardisation and training of CSs, which may help increase the safety and quality of CSs, especially in low- and middle-income settings where junior doctors perform most of these surgeries, often without supervision.

Copyright © 2026 Liesl de Waard et al. Obstetrics and Gynecology International published by John Wiley & Sons Ltd.