Cesarean delivery: Postoperative issues

Author
Vincenzo Berghella, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD
Disclosures: Vincenzo Berghella, MD Nothing to disclose. Charles J Lockwood, MD, MHCM Nothing to
disclose. Vanessa A Barss, MD Employee of UpToDate, Inc. Equity Ownership/Stock Options: Merck; Pfizer;
Abbvie.
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Literature review current through: Jul 2014. | This topic last updated: Jun 04, 2014.
INTRODUCTION This topic will review the postoperative care of women who have undergone
cesarean delivery and discuss potential sequelae of this procedure. Preoperative and
intraoperative issues are discussed separately. (See "Cesarean delivery: Preoperative
issues" and "Cesarean delivery: Technique".)
POSTOPERATIVE CARE In the immediate postoperative period, the woman is monitored for
evidence of uterine atony, excessive vaginal or incisional bleeding, and oliguria. Blood pressure is
monitored to assess for hypo or hypertension, which could be signs of intraabdominal bleeding or
preeclampsia, respectively.
Patient controlled opioid analgesia followed by oral nonsteroidal antiinflammatory drugs provides
adequate pain relief for most women. (See "Anesthesia for cesarean delivery", section on
'Planning postcesarean analgesia'.)
There is no evidence that routine urine culture or a trial of catheter clamping is useful before
removal of the bladder catheter [1,2]. Although a meta-analysis reported antibiotic administration
prior to catheter removal reduced rates of catheter-associated urinary tract infection [3], there
were multiple limitations to these trials (see "Catheter-associated urinary tract infection in adults",
section on 'Antimicrobial prophylaxis'). We do not recommend this intervention.
The mother can be instructed in ways to hold her newborn to avoid contact with the incision; lying
on her side or a 'football hold' may be used, or a pillow may be placed over the incision and under
the infant so the direct contact with the incision is minimized. Heavy lifting and lifting from a squat
position confer the greatest increases in intraabdominal pressure [4,5]. These activities should
probably be minimized in the first one to two weeks of wound healing, although there are no data
regarding the impact of various intraabdominal pressures on wound healing [6].
Early ambulation (when the effects of anesthesia have abated) and oral intake (within six hours of
delivery) are encouraged. In a 2013 systematic review (14 randomized trials and 3
nonrandomized trials), early intake of oral fluids or food after cesarean delivery was well tolerated
and had no adverse effects on time to bowel action/passing flatus or frequency of nausea,
vomiting, paralytic ileus, or analgesic use [7]. Early oral intake may enhance the return of bowel
function by stimulating the gastrocolic reflex.
The usual drugs/procedures associated with cesarean birth are not a contraindication to
breastfeeding.
Routine postoperative hemoglobin testing is not necessary in asymptomatic patients after
planned cesarean delivery, as the information does lead to improved outcomes [8]. There are no
studies evaluating such testing after cesareans performed during labor.
In a clean surgical wound, the epithelial cells migrate downward to meet deep in the dermis.
Migration ceases when the layer is rejuvenated; this is normally completed within 48 hours of
surgery. This superficial layer of epithelium creates a barrier to bacteria and other foreign bodies.
However, it is very thin, easily traumatized, and gives little tensile strength. Based on these
principles of wound healing, we remove staples about three to four days post-operatively if the
skin incision was transverse, as there is minimal tension on the skin edges, especially
postpartum. We would consider keeping the staples in longer (eg, until five to seven days
postoperatively) in women with risk factors for wound complications, such as those with diabetes
mellitus or obesity. If a vertical incision was performed, the staples are left in place for at least five
to seven days, and longer in a patient at high risk of wound complications, since there is more
tension on the skin edges of a vertical incision. Adhesive strips may be applied after removal of
the staples to help keep the wound edges approximated. In patients who scar easily, the scar that
results from staples may be more pronounced than one produced by sutures, particularly if the
staples are left in place for prolonged periods (>5 to 15 days, depending upon the location).
(See "Principles of abdominal wall closure".)
General issues regarding the postpartum period are reviewed in detail separately.
(See "Overview of postpartum care".)
COMPLICATIONS The major nonanesthesia-related complications related to cesarean
delivery are infection, hemorrhage, injury to pelvic organs, and thromboembolic disorders.
There are no randomized trials comparing outcomes of planned vaginal versus planned cesarean
delivery for the term cephalic gestation. Moderate quality evidence shows that planned cesarean
delivery is associated with less maternal hemorrhage, longer maternal hospital stay, and greater
mild neonatal respiratory morbidity than planned vaginal delivery [9]. The risks of severe maternal
morbidity are generally higher in women with an unplanned cesarean delivery during labor
[10,11]. (See "Cesarean delivery on maternal request".)
Cesarean delivery in the second stage of labor is associated with slightly higher maternal
composite morbidity than cesarean delivery in the first stage of labor; neonatal morbidity rates are
similar for first and second stage cesareans [12].
Infection The overall risk of developing a postpartum infection is increased after cesarean
delivery compared with vaginal birth [13]. Three major causes of postpartum fever after cesarean
delivery are summarized here. An overview of the causes (infectious and noninfectious) and
treatment of postoperative fever can be found separately. (See "Postoperative fever".)
Endometritis If prophylactic antibiotics are not administered, postoperative endometritis
occurs in up to 35 to 40 percent of patients delivered by cesarean [14]. This rate is as low as 4 to
5 percent after scheduled delivery with intact membranes, and as high as 85 percent after an
extended labor with ruptured membranes. Clinical manifestations, diagnosis, and treatment of
endometritis are discussed in detail separately. (See "Postpartum endometritis".)
By comparison, use of prophylactic antibiotics reduces the overall rate of infection by
approximately two-thirds. (See "Cesarean delivery: Preoperative issues".)
The method of placental extraction can also affect the incidence of postpartum endometritis.
(See "Cesarean delivery: Technique", section on 'Placental extraction'.)
Wound infection Wound infection is diagnosed in 2.5 to 16 percent of patients [15], generally
four to seven days after the cesarean. In a large case-control study of risk factors for surgical site
infection, 5 percent of 1605 low transverse incisions for cesarean delivery became infected [16].
Approximately 40 percent of the infections were diagnosed after hospital discharge, and the
major independent risk factor was development of a subcutaneous hematoma (OR 11.6, 95% CI
4.1-33.2). Prophylactic interventions, such as antibiotic administration and good surgical
technique, decrease the incidence of wound infection and disruption. (See "Cesarean delivery:
Technique".)
Early wound infections (in the first 24 to 48 hours) are usually due to group A or B beta-hemolytic
streptococcus and are characterized by high fever and cellulitis. Later infections are more likely to
be due to Staphylococcus epidermidis or aureus, Escherichia coli, Proteus mirabilis, or
cervicovaginal flora [17,18].
Wound infections associated with cellulitis alone can be treated with a course of a broad-
spectrum antibiotic, such as a cephalosporin. Initial treatment of a wound containing pus consists
of opening the wound to allow drainage, cleansing with irrigation, sharp debridement as needed,
placement of appropriate dressings (eg, alginates, foams and hydrocolloids, dressings containing
antiseptics such as antimicrobial honey, cadexomer iodine or silver), and close attention to
subsequent wound care. Superficial incisional infections that have been opened can usually be
managed without antibiotics.
For more severe infections, especially when there is evidence of extension into adjacent tissue or
systemic signs, empirical treatment is started using broad spectrum antibiotics with coverage of
the expected flora at the site of operation, as well as gram positive cocci from the skin. Definitive
antimicrobial treatment is guided by the clinical response of the patient and, when available,
results of wound culture and sensitivity. However, wound swab cultures often reveal polymicrobial
growth, making it difficult to distinguish colonization from true infection.
Wound care products (calcium alginate, enzymatic debriders, films and foams, hydrogel) and
negative pressure (vacuum) wound therapy are used as indicated for the type of wound.
(See "Complications of abdominal surgical incisions", section on 'Surgical site
infection' and "Negative pressure wound therapy".)
Necrotizing fasciitis is rare (0.18 percent of cesarean deliveries) [19]. (See "Necrotizing soft tissue
infections".)
OVT and DSPT There are two types of septic pelvic thrombophlebitis (SPT): ovarian vein
thrombophlebitis (OVT) and deep septic pelvic thrombophlebitis (DSPT). These two entities share
common pathogenic mechanisms and often occur together, but they may differ in their clinical
presentations and diagnostic findings.
Patients with OVT usually present with fever and abdominal pain within one week after delivery or
surgery, and thrombosis of the right ovarian vein is visualized radiographically in about 20 percent
of cases. Patients with DSPT usually present within a few days after delivery or surgery with
unlocalized fever that persists despite antibiotics, in the absence of radiographic evidence of
thrombosis. (See "Septic pelvic thrombophlebitis".)
Hemorrhage The mean blood loss at cesarean is approximately 1000 mL; however, estimates
of blood loss are not very reliable [20,21]. About 2 to 3 percent of all patients undergoing
cesarean delivery require blood transfusion [22]. Good surgical technique can decrease the
incidence of hemorrhage. (See "Cesarean delivery: Technique".)
Hemorrhage may be due to uterine atony, placenta accreta, extensive uterine injury, or extension
of the incision into the uterine vessels. Lacerations extending into the lateral vagina and broad
ligament should be thoroughly evaluated and repaired with meticulous attention to the position of
the ureter. It may be necessary to divide the round ligaments and open the broad ligament to
isolate and ligate the bleeding vessel. (See "Overview of postpartum hemorrhage".)
Urinary tract or bowel problems
Injury Urinary and gastrointestinal tract injuries are uncommon, occurring in fewer than 1
percent of pelvic surgical procedures [23]. The incidence of bladder injury in a series of almost
15,000 cesareans was 0.28 percent (incidence in primary and repeat cesareans: 0.14 and 0.56
percent, respectively) [24]. The risk of cystotomy is higher for cesareans performed in the second
stage compared to the first stage [12]. Ureteral injury is rare, occurring in less than 0.1 percent of
cesareans [25,26].
Injury is most likely to occur during creation of the bladder flap or upon entry into the peritoneum.
Risk factors for visceral injury include scarring from previous pelvic surgery, unplanned cesarean,
and cesarean hysterectomy. The occurrence of bladder injuries may be minimized by avoiding
significant bladder distention during surgery (eg, having the patient void preoperatively or use of a
catheter), operating as far from the bladder as is feasible, and assuring transparency of the
parietal peritoneum before cutting when sharp dissection is necessary.
Early diagnosis and immediate repair of urinary tract and bowel injuries are important to prevent
serious sequelae, such as sepsis, renal damage, and fistulae. Small cystotomies in the dome of
the bladder are easily approached with a two-layer closure of delayed absorbable suture and 4 to
7 days of catheter drainage. However, large cystotomies and those in the posterior wall of the
bladder or near the trigone may involve the ureter. Large lateral uterine or cervical extensions
may also involve the ureter. In these cases, placement of ureteral stents can aid in both diagnosis
and repair, which are performed according to standard procedures described in detail separately.
Diagnosis and management of these injuries is discussed in detail separately.
(See "Complications of gynecologic surgery", section on 'Urinary tract injuries' and "Complications
of gynecologic surgery", section on 'Bowel injury'.)
A best practice policy statement on urologic surgery antimicrobial prophylaxis from a panel of the
American Urological Association recommended antibiotic prophylaxis for surgery involving entry
into urinary tract [27]. The preferred antibiotic was a first or second generation cephalosporin, or
an aminoglycoside plus metronidazole or clindamycin; alternatives were ampicillin/sulbactam or a
fluoroquinolone. The recommended duration of therapy was 24 hours. Thus, standard antibiotic
prophylaxis given prior to cesarean delivery should be adequate prophylaxis in the event of
bladder injury (fluoroquinolones should be avoided in pregnant and breastfeeding women).
For women in whom a catheter is left in place postoperatively, there is limited evidence of benefit
(eg, reduction in bacteriuria) from continuing antimicrobial therapy for the first three postoperative
days or until catheter removal [28] or giving antibiotic prophylaxis at catheter removal [29].
Ileus Prevention and management of postoperative ileus are discussed separately.
(See "Postoperative ileus".)
Postoperative ileus after cesarean delivery may be related to Ogilvie's syndrome. (See "Acute
colonic pseudo-obstruction (Ogilvie's syndrome)".)
Venous thrombosis and embolism The risk of postpartum venous thromboembolism was
illustrated by two large studies:
In one series involving 395,335 women with live births, the incidence of deep vein
thrombosis (DVT) (178 per 100,000 births) was approximately four-fold higher after
cesarean than after vaginal delivery [30].
In another series of 268,525 births over an 11-year period, pulmonary embolus (but not
DVT) was strongly associated with cesarean delivery (19 of 36,470 cesareans compared
with 4 of 232,032 vaginal deliveries, or 52/100,000 cesareans versus 1.7/100,000vaginal
deliveries) [31].
Thromboprophylaxis is recommended to decrease the risk of thromboembolism. The type of
thromboprophylaxis (mechanical, pharmacologic, or both) is based on patient-specific risk factors.
(See "Cesarean delivery: Preoperative issues", section on 'Thromboembolism prophylaxis'.)
Wound disruption Disruption (or opening) of the cesarean laparotomy wound is not
uncommon, especially in women with risk factors (eg, obesity, diabetes, history of wound
disruption, vertical incision, etc) or infection. The rate of wound disruption in an uninfected wound
has been reported to be 1.7 percent [17]. Fascial dehiscence is uncommon (0.3 percent of
cesarean deliveries)
Reclosure (ie, secondary closure) with sutures is preferable to healing by secondary intention;
healing time is significantly faster (up to two to three weeks versus several weeks to months) and
with fewer office visits [19,32]. Reclosure with permeable adhesive tape may be both faster and
associated with less pain than reclosure with sutures [33]. Optimal timing of reclosure is
controversial, but probably four to six days after disruption is reasonable if the wound is not
infected. (See "Complications of abdominal surgical incisions".)
Psychological outcome Some of the studies attempting to evaluate maternal psychological
outcomes after vaginal versus planned and unplanned cesarean have reported that women who
deliver by cesarean express less satisfaction with their birth experience, are less likely to
breastfeed, and take longer before their first interaction with their newborn [34]. In addition, some
women have strong feelings of loss, failure, and anger [35].
These differences are likely related, at least in part, to the anxiety associated with medical and
obstetrical complications necessitating abdominal delivery (especially unplanned abdominal
delivery); the stress, pain, and fatigue associated with major surgery; and the psychological
status of the parturient. Improved psychological outcomes may be realized by realistic
preparation for childbirth, maternal involvement in decision making, and attention to the specific
needs of the woman who is both postpartum and postoperative [35].
Fetal and neonatal risks Although cesarean delivery is usually performed for the benefit of
the fetus, there are also fetal risks associated with cesarean birth. These risks include iatrogenic
prematurity and birth trauma; the latter occurs in 0.4 to 3 percent of cesareans and consists
mostly of mild lacerations related to emergency delivery [36-40]. The frequency of birth trauma by
mode of delivery is illustrated in the table (table 1).
Transient tachypnea of the newborn (TTN) is more common after scheduled or planned cesarean
birth, probably because mechanisms to reabsorb lung fluid have not been initiated. In a review of
29,669 deliveries, the incidence of TTN was about three times higher after planned cesarean than
after vaginal delivery (3.1 versus 1.1 percent) [41]. Cesarean delivery has also been reported to
be a modest risk factor for respiratory distress syndrome (RDS), particularly if the cesarean was
performed in a nonlaboring patient [42]. However, this study did not clearly discriminate between
TTN and RDS. (See "Transient tachypnea of the newborn".)
Maternal mortality A significant proportion of the surgical mortality (and morbidity) of
cesarean delivery is related to the underlying medical and obstetrical factors that necessitated the
surgical delivery in the first place. In addition, since many planned vaginal deliveries are
ultimately delivered by cesarean, these cases need to be taken into account when reporting the
mortality and morbidity of vaginal birth.
These relationships were illustrated in a study from the Netherlands of deliveries between 1983
and 1992 [43]. The risk of dying after vaginal birth was 0.04 per 1000 vaginal births compared to
0.53 per 1000 cesarean births; however, the risk of dying directly attributable to cesarean was
much lower, 0.13 per 1000 operations. (See "Cesarean delivery on maternal request", section on
'Potential disadvantages and risks of planned cesarean'.)
The case fatality rate associated with general anesthesia is higher than with regional techniques,
estimated at 32 and 1.9 maternal deaths per million live births, respectively [44].
(See "Anesthesia for cesarean delivery".)
LONG-TERM RISKS Long-term risk of morbidity significantly increases with the number of
cesarean deliveries performed [45,46]. (See "Repeat cesarean delivery", section on 'Is there an
unsafe number of repeat cesarean deliveries?'.)
Abnormal placentation Cesarean delivery significantly increases the risk of abnormal
placentation in future pregnancies. (See "Repeat cesarean delivery", section on 'Complications
relating to abnormal placentation'.)
In a meta-analysis of observational studies, the risk of placenta previa after one cesarean delivery
was 10/1000 versus 28/1000 after 3 cesarean deliveries (risk of placenta previa in the general
obstetrical population is 4/1000) [47]. (See "Clinical features, diagnosis, and course of placenta
previa".)
The higher rate of placenta previa is of concern, due to the inherent risks of this disorder and
because of the increased frequency of placenta accreta in women with placenta previa and a
prior hysterotomy. The risk of placenta accreta increases with increasing numbers of prior
cesarean deliveries even in the absence of placenta previa. (See "Clinical features and diagnosis
of placenta accreta, increta, and percreta".)
Given the increased risks of abnormal placentation, experts recommend that women who have
had a cesarean delivery should have their placental site evaluated by ultrasound in future
pregnancies [48].
Placental abruption is another example of a placental abnormality that occurs more often in
women with a prior cesarean birth [49-52]; however, the risk of abruption does not appear to
increase with increasing numbers of prior cesarean deliveries [53]. (See "Placental abruption:
Clinical features and diagnosis".)
Unexplained stillbirth The effect of cesarean delivery on future stillbirth is controversial. A
2013 systematic review and meta-analysis reported a significant positive association between
cesarean delivery and stillbirth anytime in a subsequent gestation; the significant association was
present for both explained stillbirth (OR 2.1) and unexplained stillbirth (OR 1.47) (but not
unspecified stillbirth) and for primiparous women (OR 1.3) (but not multiparous women) [54].
However, the analysis excluded the largest published study, which included almost 1.8 million
singleton second births in women with no underlying medical conditions and fetuses with no
structural or chromosomal abnormalities and found no association between previous cesarean
and future term fetal demise [55]. In this study, the fetal death rates at term in those with and
without a previous cesarean delivery were 0.7 and 0.8 per 1000 births, respectively. In the entire
cohort of over 11 million singleton births (second and subsequent births), the fetal death rates at
term for women with and without a previous cesarean were 0.4 and 0.6 per 1000 births,
respectively.
Subfertility A 2013 systematic review including 18 cohort studies and almost 600,000 women
reported that women who underwent a cesarean delivery had a 10 percent lower rate of
subsequent pregnancy than women who delivered vaginally [56]. This association appears to be
due to confounding factors that affected both the need for cesarean delivery and the choice of
subsequent pregnancy [57,58]. There is also some evidence that subfertile women are more
likely to deliver by cesarean and that women who deliver by cesarean take longer to conceive
future pregnancies [59]. However, there is no strong evidence of a causal relationship between
cesarean delivery in a first pregnancy and subfertility [60]. The effect of multiple cesareans on
fertility has not been evaluated.
Scar complications Rarely, complications develop in the scars resulting from hysterotomy or
abdominal incision:
Hysterotomy scar pregnancy Ectopic pregnancy in a previous hysterotomy
(cesarean) scar occurs in about 1 in 2000 pregnancies and 6 percent of ectopic
pregnancies among women with a prior cesarean delivery [61]. Risk does not appear to be
related to the number of cesarean deliveries. The pregnancy is located in the scar outside of
the uterine cavity and surrounded by myometrium and connective tissue. Implantation in this
location is believed to occur because the embryo migrates through a defect within the scar.
Symptoms and diagnosis are similar to tubal ectopic pregnancy. There are no data on the
role of the interval between the previous cesarean delivery and hysterotomy scar pregnancy
occurrence or the effect of wound closure technique on its occurrence. (See "Abdominal
pregnancy, cesarean scar pregnancy, and heterotopic pregnancy".)

The overall rate of ectopic pregnancy is not increased after cesarean delivery [62].
Numbness or pain Branches of the ilioinguinal nerve and the iliohypogastric nerve are
severed by transverse abdominal incisions. This often causes a lasting numbness in the
region around the scar. Less commonly, patients have a lasting, radiating, invalidating pain
due to nerve entrapment [63-67]. The diagnostic triad of nerve entrapment after surgery
includes: (1) typical burning or lancinating pain near the incision that radiates to the area
supplied by the nerve, (2) clear evidence of impaired sensory perception of the nerve, and
(3) pain relieved by local infiltration with an anesthetic [65]. Treatment involves surgical
repair of the scar with resection of the compromised nerve or nerve block [68]. (See "Nerve
injury associated with pelvic surgery".)
Incisional endometriosis Incisional endometriosis is another rare complication of
cesarean delivery, occurring in 0.1 percent of patients who have delivered by cesarean [69].
It presents as a tender palpable mass in the incision [70,71]. The mass increases during
menstruation and is associated with cyclic or continuous pain. Differential diagnosis includes
incisional hernia. The diagnosis and management of endometriosis at unusual sites is
discussed separately. (See "Pathogenesis, clinical features, and diagnosis of
endometriosis", section on 'Sites'.)
Postmenstrual spotting A uterine niche (ie, an indentation at the endometrial side of
the cesarean scar) is relatively common after cesarean delivery and may be associated with
postmenstrual spotting [72].
Uterine rupture in a subsequent term pregnancy The incidence of uterine rupture is higher
in women who undergo trial of labor after cesarean delivery (TOLAC) and lower in women who
undergo elective repeat cesarean delivery (ERCD). The incidence varies depending on the type
and location of the prior uterine incision, as well as other factors. (See "Uterine dehiscence and
rupture after previous cesarean delivery".)
Adhesions Abdominal surgery is associated with long-term risks from development of
clinically significant adhesions, which can be completely asymptomatic or can cause significant
morbidity and mortality as a result of strangulation, obstruction, and necrosis of bowel;
infertility; and/or organ injury during repeat abdominal surgery. Formation of adhesions is
common after cesarean delivery, and the extent and density increase with increasing numbers of
repeat cesarean deliveries: the reported prevalence of adhesions is 12 to 46 percent of women at
their second cesarean and 26 to 75 percent of women at their third cesarean [73-77]. The rate of
bowel obstruction after cesarean delivery is much lower, ranging from 0.5 to 9 per 1000 cesarean
deliveries, with the highest risk in women who have undergone multiple cesarean deliveries [78-
80]. There is no high quality evidence to support the use of adhesion barriers or closure of the
peritoneum to prevent complications from adhesions after cesarean delivery [81]. (See "Cesarean
delivery: Technique", section on 'Adhesion barriers' and "Cesarean delivery: Technique", section
on 'Peritoneum'.)
TRIAL OF LABOR AFTER A CESAREAN After a cesarean delivery, the surgeon should
describe the uterine incision in the operative note and discuss with the patient the feasibility of a
trial of labor in a future pregnancy. (See "Choosing the route of delivery after cesarean birth".)
REPEAT CESAREAN DELIVERY Issues relating to repeat cesarean delivery are discussed
separately. (See "Repeat cesarean delivery".)
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SUMMARY AND RECOMMENDATIONS
The major short-term complications related to cesarean delivery are infection, hemorrhage,
injury to pelvic organs, and thromboembolic disorders. The major long-term risks are
abnormal placentation and issues relating to route of delivery in future pregnancies.
(See 'Complications' above.)
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