Official reprint from UpToDate

www.uptodate.com 2017 UpToDate

Cesarean delivery: Postoperative issues

Author: Vincenzo Berghella, MD

Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2017. | This topic last updated: Nov 21, 2016.

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 planning and patient preparation" and
"Cesarean delivery: Technique".)

POSTOPERATIVE CARE Maternal issues and care in the postpartum period are reviewed in detail
separately (see "Overview of postpartum care", section on 'Normal postpartum anatomic and physiologic
changes'). The following brief discussion applies specifically to issues postcesarean delivery.

Maternal monitoring In the immediate postoperative period, vital signs, uterine tone, vaginal and
incisional bleeding, and urine output are monitored closely.

Vital signs that may trigger evaluation for a serious complication following cesarean delivery include systolic
blood pressure <90 mmHg, heart rate >120 beats/minute, respiratory rate >30/minute, oxygen saturation <95
percent, urine output <30 cc/hour [1]. Hypo- or hypertension can be signs of intra-abdominal bleeding or
preeclampsia, respectively.

Routine postoperative hemoglobin testing is unnecessary in asymptomatic patients after planned cesarean
delivery, as the information does not lead to improved outcomes [2]. No studies have evaluated such testing
after cesareans performed during labor, but routine evaluation of postdelivery hemoglobin is probably
unwarranted in uncomplicated, stable patients.

Analgesia (See "Management of acute perioperative pain" and "Anesthesia for cesarean delivery", section
on 'Post-cesarean delivery analgesia'.)

Bladder catheter Removing the catheter as soon as possible minimizes the risk of infection. There is no
evidence that routine urine culture or a trial of catheter clamping is useful before removal of the bladder
catheter [3,4]. Although a meta-analysis reported that antibiotic administration prior to catheter removal
reduced the rate of catheter-associated urinary tract infection [5], there were multiple limitations to these
trials. We do not recommend this intervention. (See "Catheter-associated urinary tract infection in adults",
section on 'Prevention'.)

Diet and activity 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 [6].
Early oral intake may enhance the return of bowel function by stimulating the gastrocolic reflex. Chewing gum
at least three times per day for at least 15 minutes appears to accelerate postoperative gastrointestinal
recovery [7]. (See "Measures to prevent prolonged postoperative ileus".)
Heavy lifting and lifting from a squat position confer the greatest increases in intra-abdominal pressure [8,9].
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 intra-abdominal pressures on wound healing [10]. Some
surgeons suggest that patients avoid lifting >13 pounds (6 kg) from the floor for four to six weeks following
abdominal surgery to minimize stress on the healing fascia, but no evidence-based guidelines are available.
Many obstetric clinicians advise women to avoid lifting anything heavier than the infant.

Women may slowly increase aerobic training activities, depending on their level of discomfort and postpartum
complications. There is little evidence to support specific recommendations for aerobic and strength-training
activities [11]. Pelvic floor muscle exercises can reduce urinary incontinence, if present. (See "Treatment of
urinary incontinence in women", section on 'Pelvic floor muscle exercises (Kegel exercises)'.)

Women should avoid driving if they are taking opioids or other sedatives or if they have pain with the normal
activities required of a driver (eg, turning the body or head, stepping on the brake/accelerator, steering).

Breastfeeding Breastfeeding can be initiated in the delivery room. The usual drugs/procedures associated
with cesarean birth are not a contraindication to breastfeeding. Information about use of drugs during
breastfeeding is available in the UpToDate drug database and at the LactMed drugs and lactation database.

Wound care In a clean surgical wound, epithelialization typically occurs in the 48 hours after surgery. The
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.

Although data from randomized trials are limited, removal of dressings from clean or clean, contaminated
surgical wounds within 48 hours of surgery (ie, the period of epithelization) appears to have no detrimental
effect on outcomes, compared with removal after 48 hours [12]. A trial involving 320 patients who underwent
scheduled cesarean delivery reported no detrimental effects from dressing removal at six versus 24 hours
post-surgery [13]. We usually remove the dressing 24 hours after cesarean. There is no conclusive evidence
of harm from postoperative showering within 48 hours of surgery in patients with closed surgical wounds [14].

We typically reapproximate the skin with an absorbable subcuticular suture (see "Cesarean delivery:
Technique", section on 'Skin'). If staples are used (eg, patients preference based on prior experience), we
remove them four or more days postoperatively, if the skin incision was transverse. We would consider
keeping the staples in longer (eg, up to 10 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).

COMPLICATIONS The major non-anesthesia-related complications related to cesarean delivery are

endometritis, wound complications, hemorrhage, injury to pelvic organs, and thromboembolic disorders. The
risk of severe maternal morbidity is generally higher in women with an unplanned cesarean delivery during
labor than in those with a scheduled prelabor cesarean delivery [15,16]. Cesarean delivery in the second
stage of labor is generally associated with higher maternal composite morbidity than cesarean delivery in the
first stage of labor [17].

Data from the Nationwide Inpatient Sample showed that 76 in 1000 cesarean deliveries (97 in 1000 primary
and 48 in 1000 repeat cesarean deliveries) were associated with at least one of 12 complications [18].
Absolute complication rates vary widely across hospitals [19] and by patient risk factors [20], and
complications related to placenta accreta are a particular concern in women undergoing repeat cesarean
delivery. (See "Clinical features and diagnosis of the morbidly adherent placenta (placenta accreta, increta,
and percreta)".)

Endometritis In a review of Maternal-Fetal Medicine Units (MFMU) Network prospective studies of

cesarean delivery (n = 70,000 cesareans), the rate of endometritis was 6 percent of primary cesarean
deliveries without labor and 11 percent of cesarean deliveries during labor [20].

Clinical manifestations, diagnosis, treatment, and prevention of postpartum endometritis are discussed in
detail separately. (See "Postpartum endometritis" and "Cesarean delivery: Preoperative planning and patient
preparation", section on 'Antibiotic prophylaxis'.)

Wound complications In the same review of MFMU Network prospective studies of cesarean delivery
mentioned above, wound complications (infection, hematoma, seroma, dehiscence) developed in 1 to 2
percent of primary cesarean deliveries [20].

Wound infection generally develops 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 [21]. Approximately 40 percent of the infections were diagnosed after hospital discharge, and the
major independent risk factor was development of a subcutaneous hematoma (odds ratio [OR] 11.6, 95% CI
4.1-33.2).

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 [22,23].

The basic principles of wound management (role of antibiotics, debridement, topical therapy, dressings,
packing, negative pressure, management of disruption) are reviewed in detail separately. (See
"Complications of abdominal surgical incisions", section on 'Surgical site infection' and "Basic principles of
wound management".)

Necrotizing fasciitis is a rare but life-threatening complication (0.18 percent of cesarean deliveries in one
study [24]). (See "Necrotizing soft tissue infections".)

Hemorrhage The mean estimated blood loss at cesarean delivery is approximately 1000 mL; however,
estimates of blood loss are not very reliable [25,26]. Routine administration of oxytocin after the newborn is
delivered reduces postpartum blood loss and risk of hemorrhage. (See "Anesthesia for cesarean delivery",
section on 'Prevention of postpartum hemorrhage'.)

In the same review of MFMU Network prospective studies of cesarean delivery mentioned above, 2 to 4
percent of women undergoing a primary cesarean delivery received a blood transfusion [20]. Causes of
hemorrhage include uterine atony, placenta accreta, extensive uterine injury, and extension of the incision into
the uterine vessels. (See "Overview of postpartum hemorrhage" and "Management of postpartum
hemorrhage at cesarean delivery" and "Management of hematomas incurred as a result of obstetrical
delivery", section on 'Retroperitoneal hematomas'.)

Surgical injury In the same review of MFMU Network prospective studies of cesarean delivery mentioned
above, a surgical injury (broad ligament hematoma, cystotomy, bowel injury, ureteral injury) occurred in 0.2 to
0.5 percent of women undergoing a primary cesarean delivery [20]. In another study of almost 30,000 primary
and repeat cesarean deliveries, the overall rate of lower urinary tract injury was 0.27 percent; 3 percent were
ureteral and the rest were full- or partial-thickness bladder injuries.
[27]. The risk of cystotomy is higher for cesareans performed in the second stage than in the first stage and in
repeat cesareans [17,28].

Diagnosis, management, and prevention of these injuries are discussed in detail separately. (See "Urinary
tract injury in gynecologic surgery: Identification and management" and "Urinary tract injury in gynecologic
surgery: Prevention" and "Complications of gynecologic surgery", section on 'Bowel injury'.)

Thrombotic events A study using claims data from 1.7 million pregnancies reported that the frequency of
a thrombotic event (ischemic stroke, acute myocardial infarction, venous thromboembolism) was 246 per
100,000 cesarean deliveries during the first six postpartum weeks [29]. This rate was 20-fold higher than the
rate one year later and significantly higher than the rate after vaginal delivery (165 per 100,000). (See
"Cesarean delivery: Preoperative planning and patient preparation", section on 'Thromboembolism
prophylaxis'.)

Maternal mortality Maternal mortality is rare. A significant proportion of the surgical mortality (and
morbidity) of cesarean delivery is related to the underlying medical and obstetrical factors that necessitate the
surgical delivery. One group estimated that two to six women die annually in the United States because of
cesarean delivery, which is approximately 0.2 to 0.6 maternal deaths/100,000 cesarean deliveries [30].

Anesthetic complications (See "Anesthesia for cesarean delivery".)

Ileus and colonic pseudo-obstruction Adynamic ileus of moderate and severe intensity has been
reported in 10 to 20 percent of postcesarean patients [31]. Estimates of the frequency of pathologic or
prolonged ileus after cesarean delivery are imprecise because ileus is a normal physiologic response to
abdominopelvic surgery, definitions of pathologic or prolonged ileus differ, and multiple factors affect the risk
of occurrence. Clinical findings, diagnosis, management, and prevention of postoperative ileus are discussed
separately. (See "Postoperative ileus".)

Severe postoperative ileus after cesarean delivery may be related to acute colonic pseudo-obstruction
(Ogilvie's syndrome), which is characterized by gross dilatation of the cecum and right hemicolon in the
absence of an anatomic obstruction. (See "Acute colonic pseudo-obstruction (Ogilvie's syndrome)".)

Septic pelvic thrombophlebitis Ovarian vein thrombophlebitis (OVT) and deep septic pelvic
thrombophlebitis (DSPT) are rare complications of cesarean delivery. The two entities share common
inflammatory pathogenic mechanisms and often occur together, but may differ in their clinical presentations
and diagnostic findings. Patients with OVT usually present with fever and abdominal pain localized to the side
of the affected vein within one week after delivery or surgery; thrombosis of the right ovarian vein is visualized
radiographically in approximately 20 percent of cases. Patients with DSPT usually present within a few days
after delivery or surgery with fever that persists despite antibiotics, in the absence of radiographic evidence of
thrombosis. Abdominal or pelvic tenderness is notably absent. (See "Septic pelvic thrombophlebitis".)

Psychological outcome Women who deliver by cesarean have been reported to express less satisfaction
with their birth experience, to take longer before their first interaction with their newborn, and to be less likely
to breastfeed than women delivering vaginally [32]. Some women also express strong feelings of loss, failure,
and anger [33]. These feelings 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. Better
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
[33].

Fetal and neonatal risks Although cesarean delivery is usually performed for the benefit of the fetus, the
fetus is also at risk from cesarean birth. Risks include iatrogenic prematurity and birth trauma; the latter
occurs in 1 to 3 percent of cesareans and consists mostly of mild lacerations related to emergency delivery
[34].

Transient tachypnea of the newborn (TTN) is more common after scheduled cesarean birth, probably
because exposure to labor initiates processes that enhance reabsorption of lung fluid. In a review of 29,669
deliveries, the incidence of TTN was approximately threefold higher after planned cesarean than after vaginal
delivery (3.1 versus 1.1 percent) [35]. 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 [36].
However, this study did not clearly discriminate between TTN and RDS. (See "Transient tachypnea of the
newborn".)

LONG-TERM RISKS

Abnormal placentation Cesarean delivery significantly increases the risk of abnormal placentation in
future pregnancies, and the risk increases with the number of cesarean deliveries. Given the increased risks
of abnormal placentation, experts recommend that women with a prior cesarean delivery undergo ultrasound
evaluation of the placental site in future pregnancies [37].

The risk of placenta previa in the general obstetric population, after one cesarean delivery, and after 3
cesarean deliveries was 4 in 1000, 10 in 1000, and 28 in 1000 deliveries, respectively, in one review [38].
Women with a previa and 3 cesarean deliveries were at significantly increased risk of placenta accreta,
compared with women with a previa and no previous cesarean delivery (50 to 67 percent versus 3.3 to 4
percent). The risk of placenta accreta increases with an increasing number of prior cesarean deliveries, even
in the absence of placenta previa. (See "Repeat cesarean delivery", section on 'Complications relating to
abnormal placentation'.)

Placental abruption occurs more often in women with a prior cesarean birth [39-42], but the absolute risk is
low, and the association may be due to confounders [43]. (See "Placental abruption: Clinical features and
diagnosis".)

Uterine rupture in a subsequent term pregnancy The incidence of uterine rupture is higher in women
who undergo a trial of labor after cesarean delivery (TOLAC) than 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 rupture after previous cesarean delivery".)

Scar complications Rarely, complications develop in the scars resulting from the hysterotomy or
abdominal wall incision:

Cesarean scar pregnancy A cesarean scar pregnancy is thought to result from migration of the
embryo 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 [44].

Numbness or pain Branches of the ilioinguinal nerve and the iliohypogastric nerve are severed by
transverse abdominal incisions. This often causes persistent numbness in the region around the scar.
Less commonly, patients have persistent, radiating pain due to nerve entrapment [45-49]. 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 [47]. Treatment involves surgical repair
of the scar with resection of the compromised nerve or nerve block. (See "Nerve injury associated with
pelvic surgery".)

Incisional endometriosis Incisional endometriosis has been reported in 0.1 percent of patients who
have delivered by cesarean [50]. It presents as a tender, palpable mass in the incision [51,52]. 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 "Endometriosis: Pathogenesis, clinical features, and diagnosis", section on
'Anatomic sites'.)

Postmenstrual spotting A uterine niche (ie, an indentation on the endometrial side of the cesarean
scar) is relatively common after cesarean delivery and may be associated with postmenstrual spotting
[53].

Adhesions Abdominal surgery is associated with long-term risks from development of clinically significant
adhesions. Adhesions can be completely asymptomatic or can cause significant morbidity and mortality
related to bowel obstruction, infertility, 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 [54-58]. 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 [59-61]. There is no convincing evidence to
support use of adhesion barriers or closure of the peritoneum to prevent complications from adhesions after
cesarean delivery. (See "Cesarean delivery: Technique", section on 'Adhesion barriers' and "Cesarean
delivery: Technique", section on 'Peritoneum'.)

Unexplained stillbirth The effect of cesarean delivery on future stillbirth is controversial. A 2015
systematic review and meta-analysis reported a significant positive association between cesarean delivery
and antepartum stillbirth in a second pregnancy (pooled HR 1.40; 95% CI 1.101.77) [62]. The absolute risk
difference was 0.1 percent; therefore, 1000 cesarean deliveries would need to be avoided to prevent one
additional antepartum stillbirth. 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 [63]. This study was excluded from the analysis because it included intrapartum stillbirths, which may
have a different etiology. 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.

An association between unexplained stillbirth and a prior cesarean delivery observed in some studies may be
due to residual confounding, but it is possible that scar tissue from a previous cesarean delivery may lead to
abnormal placental function leading to stillbirth.

Subfertility In a 2013 systematic review including 18 cohort studies and almost 600,000 women, women
who underwent a cesarean delivery had 10 percent fewer subsequent pregnancies than women who
delivered vaginally [64]. This association appears to be due to confounding factors that affected both the
need for cesarean delivery and the choice of subsequent pregnancy [65,66]. 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 [67]. However, there is no convincing evidence of a causal relationship
between cesarean delivery in a first pregnancy and subfertility [68] or cesarean surgical technique and
subfertility [69]. The effect of multiple cesareans on fertility has not been evaluated.

Asthma in offspring An association between scheduled or unscheduled cesarean delivery and asthma
and bronchiolitis in offspring has been reported [70-72].

FUTURE DELIVERY

Trial of labor after a cesarean After a cesarean delivery, the surgeon should describe the uterine incision
clearly in the operative note and begin a discussion with the patient about 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".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics
and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on patient info and the keyword(s) of interest.)

Basics topics (see "Patient education: C-section (cesarean delivery) (The Basics)")

Beyond the Basics topics (see "Patient education: C-section (cesarean delivery) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Routine postoperative hemoglobin testing is unnecessary in asymptomatic patients after planned

cesarean delivery, as the information does not lead to improved outcomes. Routine evaluation of
postdelivery hemoglobin is probably unwarranted after uncomplicated intrapartum cesarean delivery.
(See 'Maternal monitoring' above.)

Patient-controlled opioid analgesia followed by oral nonsteroidal anti-inflammatory drugs provides

adequate pain relief for most women. (See 'Analgesia' above.)

Removal of the bladder catheter as soon as possible postpartum minimizes the risk of infection. (See
'Bladder catheter' above.)

Breastfeeding can be initiated in the delivery room. The usual drugs/procedures associated with
cesarean birth are not a contraindication to breastfeeding. (See 'Breastfeeding' above.)

Early ambulation (when the effects of anesthesia have abated) and oral intake (within six hours of
delivery) are encouraged. Women may slowly increase aerobic training activities, depending on their
level of discomfort and postpartum complications. Pelvic floor muscle exercises can reduce urinary
incontinence, if present. (See 'Diet and activity' above.)

Dressings can be removed, and patients may shower within 48 hours of surgery. (See 'Wound care'
above.)
 The frequency of short-term complications after primary cesarean delivery is: ileus (10 to 20 percent),
endometritis (6 to 11 percent), wound complications (1 to 2 percent), hemorrhage requiring transfusion (2
to 4 percent), surgical injury (0.2 to 0.5 percent), and thrombotic events (246 per 100,000). (See
'Complications' above.)

Neonatal risks include iatrogenic prematurity, respiratory problems, and birth injury. (See 'Fetal and
neonatal risks' above.)

The major long-term risks of cesarean delivery are abnormal placentation (previa, accreta) and uterine
rupture during a trial of labor in future pregnancies (see 'Abnormal placentation' above and 'Uterine
rupture in a subsequent term pregnancy' above). The risk of abnormal placentation increases with an
increasing number of cesarean deliveries. The rate of bowel obstruction after cesarean delivery ranges
from 0.5 to 9 per 1000 cesarean deliveries, with the highest risk in women who have undergone multiple
cesarean deliveries. (See 'Adhesions' above.)

Long-term abdominal scar complications include numbness, pain, and endometriosis. Uterine scar
complications include cesarean scar pregnancy and postmenstrual spotting. (See 'Scar complications'
above.)

Cesarean delivery does not appear to be an independent risk factor for future unexplained stillbirth or
subfertility. (See 'Unexplained stillbirth' above and 'Subfertility' above.)

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Topic 4459 Version 43.0

Contributor Disclosures
Vincenzo Berghella, MD Nothing to disclose Charles J Lockwood, MD, MHCM Consultant/Advisory
Boards: Celula [Aneuploidy screening (No current products or drugs in the US)]. Vanessa A Barss, MD,
FACOG Nothing to disclose

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