DOI: 10.1111/tog.

12280 2016;18:265–72
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Complications of caesarean section

a, b
Alexander Field BSc MBBS PGCertMedEd MRCOG, * Rahim Haloob FRCOG
a
Specialist Registrar in Obstetrics and Gynaecology, Department of Women and Children’s Health, Colchester Hospital University Foundation
Trust, Colchester, Essex CO4 5JL, UK
b
Consultant Obstetrician and Gynaecologist, Department of Women and Children’s Health, Basildon and Thurrock University Hospital Trust,
Basildon, Essex SS16 5NL, UK
*Correspondence: Alexander Field. Email: alexander.field@doctors.org.uk

Accepted on 11 January 2016

Key content Learning objectives

 The incidence and presentation of complications of
caesarean section.
 The surgical management of intrapartum and
postpartum haemorrhage.
 Risk factors for, and prevention and treatment of
postpartum sepsis.
 Presentation, investigation and repair of bladder injuries
when recognised intraoperatively and following
delayed presentation.
 Risk factors for, and recognition and management of suspected
ureteric injury intraoperatively and postoperatively.
 Bowel complications including intraoperative bowel
injury and management, postoperative ileus and
Ogilvie syndrome.
 Particular risks and complications associated with caesarean
section at full dilatation.
 Caesarean section in the developing world.
 To be aware of the most common and serious complications of
caesarean section.
 To be able to describe recognition and initial surgical management
of suspected bladder, ureteric and bowel injuries.
 To be familiar with delayed presentations of visceral injuries and
have a systematic approach to investigation of suspected injury.
 To understand the impact of caesarean section complications in
resource-poor countries.
Ethical issues
 Appropriate, accurate preoperative counselling regarding risks
and consent.
 Awareness of personal competency in managing
specific complications.
Keywords: caesarean section / complications / haemorrhage / ileus /
Ogilvie syndrome / sepsis / visceral injury
Linked resource: Single best answer questions are available for this
article at https://stratog.rcog.org.uk/tutorial/tog-online-sba-resource

Please cite this paper as: Field A, Haloob R. Complications of caesarean section. The Obstetrician & Gynaecologist 2016;18:265–72. DOI: 10.1111/tog.12280

be encountered and the obstetrician must be familiar with

Introduction
and able to rectify these.
Caesarean section is one of the commonest operations
performed in the UK and its incidence is increasing.
Haemorrhage
According to the Hospital Episode Statistics data for
2013–2014 the caesarean section rate for England was Caesarean section is a risk factor for postpartum
26.2% (or 166 081 operations), an increase on the previous haemorrhage, although a wide range of definitions and
year.1 In addition to the increasing rates in developed risks are quoted in the literature. The National Institute
countries, rates are increasing in some developing for Health and Care Excellence (NICE) guideline on
countries.2 The majority of these proceed smoothly and caesarean section gives a rate of 1.1% for postpartum
safely; however, caesarean section is a major, open haemorrhage following planned caesarean section versus
abdominal procedure, often performed in an emergency 6.0% for planned vaginal birth (although in the study
setting. The incidence of re-laparotomy after caesarean that NICE obtained these figures from, 35% of women
section is 0.12–1.04%,3,4 the most common indications in this group actually had an unplanned
being intra-abdominal bleeding, intra-abdominal abscess or caesarean section).5
bladder and bowel complications.4 As such, there are a Magann et al.6 looked at over 4000 caesarean deliveries in
number of immediate and delayed complications that may Australia. The incidence of postpartum haemorrhage in

ª 2016 Royal College of Obstetricians and Gynaecologists 265

 Complications of caesarean section
emergency caesarean was 6.75% and 4.74% for elective
caesarean. Risk factors included placenta praevia, general
anaesthesia, obesity, labour dystocia, antepartum/
intrapartum haemorrhage, birthweight of greater than 4 kg
and the presence of uterine fibroids.6
Haemorrhage at caesarean occurs for a number of reasons,
including uterine atony, tissue trauma (for example, uterine
angle extensions, cervico-vaginal trauma, bladder injury or
bleeding from adhesions), coagulation defects and problems
with the placenta. The treatment of haemorrhage at caesarean
must be directed at the cause. Uterine atony is treated with
uterotonic medications, such as syntocinon, ergometrine,
carboprost and misoprostol. If these fail, surgical methods
such as intrauterine tamponade balloon and/or compression
sutures (for example, B Lynch) should be employed.7
Bleeding due to trauma can be minimised by using a
careful surgical technique. The uterus should be checked for
dextro-rotation and this should be corrected prior to uterine
incision. Similarly, care should be taken to avoid opening the
uterus too inferiorly, especially in the advanced stages of
labour when the lower segment may be difficult to delineate.
The fetal head should be gently disimpacted and delivered
through the uterine incision. These measures reduce the risk
of uterine angle extensions, broad ligament trauma and
urinary tract injury.7
Bleeding as a result of trauma should be arrested by
prompt surgical repair. Uterine angle extensions should be
repaired, ensuring that the angles are adequately secured.
Extensions downwards and laterally may be close to the
ureters. Tears in the lower segment extending downwards
towards the bladder should be closed from apex to
incision.7 The bladder may need to be mobilised further
to prevent inclusion within sutures but should also be
checked to ensure it is not damaged. Extensions upwards
into the upper segment should be closed in a similar
fashion to a classical caesarean section, carefully
documented and accompanied by advice for future
deliveries.7 There may be a complete hole in the broad
ligament and possible extension into the posterior aspect of
the uterus; this hole should be closed to prevent bowel
herniation. Within the broad ligament lie both branches of
the uterine arteries as well as the uterine arteries themselves,
which can be torn. Haemostatic sutures can be placed to
secure bleeding and, if needed, the uterine vessels can be
ligated. This is done by taking a suture through the lateral
aspect of the uterus at the level of the incision and back
through an avascular window within the broad ligament, or
the broad ligament can be opened.7
Bleeding from the placental bed, such as with placenta
praevia or placenta accreta, can be managed with figure of
eight haemostatic sutures or intrauterine balloon
tamponade.7 Intravenous tranexamic acid may be a useful
adjunct in all cases of haemorrhage.8
266
Should initial surgical and medical attempts to arrest
bleeding fail, there are several second-line options. Some
units have access to interventional radiology services that are
able to find and embolise specific bleeding points and,
ideally, patients with morbidly adherent placenta should
deliver in a unit with access to interventional radiology.
Internal iliac artery ligation may be attempted, although this
is a procedure many obstetricians are not familiar with.
Ultimately, hysterectomy may be necessary; although when
done at caesarean it is associated with high rates of
complications, including bladder trauma, ureteric injury
and re-laparotomy as discussed by Sackinki et al.9 in their
case series.
Postoperative sepsis
Caesarean section is the most important risk factor for
postpartum sepsis, which may arise from a number of
sources. Wound infection and endometritis are the
commonest sites of postoperative infection, although the
urinary tract, respiratory tract and nervous system must also
be considered. The risk of sepsis is, unsurprisingly, higher for
emergency compared with elective caesarean section. A 2014
Cochrane review suggested a rate of wound infection of 97
per 1000 and 68 per 1000 for emergency and elective
caesarean section, respectively; for endometritis the rates
were 184 per 1000 versus 39 per 1000.10 The review also
showed that prophylactic antibiotics led to a relative risk of
endometritis of 0.38 (95% confidence interval [CI]
0.34–0.42),10 hence prophylactic antibiotics prior to skin
incision are one of the most important ways of reducing
postoperative sepsis.10 Meticulous attention to haemostasis
and appropriate consideration and placement of drains may
also lead to a reduction in postoperative collections.11
Wloch et al.12 examined other risk factors and found that
obesity and maternal age under 20 years were independent
risk factors for surgical site infection, and that rates of
infection were lowest when the caesarean section was
performed by a consultant.12 The overall rate of surgical site
infection was 9.6% and the commonest organisms isolated
were Staphylococcus aureus, anaerobes and enterobacteriaceae
such as Escherichia coli (E. coli) and enterococcus.12
A Cochrane review from 2014 found that routine
preoperative vaginal cleansing with povidone-iodine
solution reduced the risk of postpartum endometritis
(relative risk 0.45, 95% CI 0.25–0.81) but showed no
statistically significant effect on wound infection or pyrexia.13
There is little definitive evidence regarding wound closure
and the risk of sepsis. A 2012 Cochrane review examined
wound closure techniques at caesarean section.14 The two
most commonly compared methods were staples and
subcuticular absorbable sutures. There was no statistically
significant difference in terms of pain, cosmetic appearance
ª 2016 Royal College of Obstetricians and Gynaecologists

or infection rates. Staples were associated with a slightly
higher risk of skin separation after removal but the definition
of skin separation was heterogeneous across the studies, as
was the time of staple removal (in some studies staples were
removed on day 3 postoperatively).14
There is also little evidence regarding the treatment of
postoperative sepsis. The initial priority is haemodynamic
stabilisation and administration of broad spectrum
antibiotics active against likely organisms. Appropriate
cultures should be taken, ideally prior to administering but
not delaying the antibiotics; these may be wound swabs,
blood cultures, urine cultures or vaginal swabs. Wound pain,
erythema and offensive discharge are suggestive of superficial
infection whereas endometritis is characterised by heavy
lochia, which may be offensive and associated with
abdominal pain. Imaging is often requested but may be
difficult to interpret. A study from 2004 reviewed 100 women
who underwent caesarean section followed by routine
ultrasound scan postoperatively on day 4. Interestingly,
48% had ultrasound evidence of a fluid collection either
within the abdominal wall or the abdominal cavity and the
study concluded that the presence of this was not associated
with postoperative morbidity.15
A small proportion will not respond to conservative
management. In these women, it seems sensible to perform
imaging before proceeding to surgical intervention. There is
little published literature to guide management. Some will
need formal surgical exploration of the wound, and, if
required, the abdominal cavity. Aspiration of any collection,
pelvic washout and drain insertion may suffice. Deep seated
infection may need debridement and re-closure of the uterine
incision. Other women may be managed with radiological-
guided drainage of the collection. It may be wise, especially if
there are risk factors for poor wound healing, to seek an
opinion from the tissue viability team or a vascular surgeon
concerning re-closure of the abdominal wound. It may be
necessary to debride the wound back to vitalised tissue and
close with interrupted sutures or staples to allow drainage.
There is little specific evidence concerning negative pressure
wound therapy in this situation but it may have a role,
especially in women with risk factors such as high body mass
index, diabetes or smoking.16
Puerperal necrotising fasciitis is uncommon and may
follow vaginal delivery or caesarean section. The
physiological immunosuppression of pregnancy may be
augmented by significant anaemia, malnutrition or
diabetes.17 The clinical presentation is with pain out of
proportion to the clinical findings and accompanied by
extremely rapid disease progression. Infection may be
polymicrobial.17 Initial treatment of infection is broad
spectrum antibiotics, fluid resuscitation and senior
multidisciplinary review because early, extensive surgical
debridement is required.
ª 2016 Royal College of Obstetricians and Gynaecologists
Field and Haloob
Bladder injury
Bladder injury at caesarean section is uncommon. The
Royal College of Obstetricians and Gynaecologists
(RCOG) suggests there is a rate of 1 in 1000, whereas a
large case–control study from Turkey looking at over
56 000 caesarean sections reported an incidence of 0.13%.18
Risk factors from this study included age, parity, previous
caesarean section, previous pelvic surgery, the presence of
adhesions, station of presenting part lower than or equal to
+1 cm, birthweight more than 4 kg, and caesarean section in
labour, although these are not necessarily independently
associated. Bladder injury has been reported more frequently
in those attempting vaginal birth after caesarean compared
with those undergoing elective repeat caesarean section.19 In
primary caesarean section, most bladder injuries occurred
during peritoneal entry whereas in repeat caesarean section,
most occurred during dissection of the bladder from the
lower uterine segment (bladder flap creation).18
There is an argument for avoiding routine creation of a
bladder flap as several case series have reported this as a time
when bladder trauma may occur. There is also evidence that
omitting this step reduces bleeding and operative times;
however, there is no evidence that this reduces the rates of
bladder injury, largely because of the difficulty in performing
an adequately powered study.20
Bladder injury has an excellent prognosis if recognised
intraoperatively and appropriately repaired. There should be a
high suspicion of injury if peritoneal entry was difficult or if
there are significant pelvic adhesions. Injury may be obvious,
with a visible laceration to the bladder, extravasation of urine,
visible catheter balloon, frank haematuria or significant
bleeding not arising from the uterine incision.18 Retrograde
instillation of methylene blue may be useful if injury is
suspected but not obvious, and to check the integrity of repair
once complete. Most injuries involve the dome of the bladder
and may be closed with an absorbable suture by an experienced
obstetrician using a 2-layer technique. However, extensive
bladder injury, especially if there is a suspicion of ureteric or
ureteric orifice involvement, should be repaired by a
urologist.18 Postprocedure management includes indwelling
catheter drainage and prophylactic antibiotics for 10–14 days.
After this, a cystogram may be performed to check bladder
integrity and the catheter removed.
If bladder injury is not detected intraoperatively, it may
present with urinary ascites, urine draining from an
abdominal drain, oliguria from a catheter with otherwise
normal observations, deranged renal function secondary to
peritoneal reabsorption of urea and electrolytes,21
incontinence due to vesico-uterine fistula or intra-
abdominal haemorrhage.18 In this case, urological opinion
is vital and re-operation the likely outcome. Imaging is
usually by computed tomography (CT) cystogram after
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 Complications of caesarean section
retrograde bladder filling with contrast via an indwelling
catheter. If there is a suspicion of upper renal tract injury as
well or diagnostic uncertainty, CT with intravenous contrast
may be required.22
Ureteric injury
Ureteric injury at caesarean section is substantially less
common than bladder injury but much less likely to
be recognised intraoperatively.23 A large audit of
11 284 caesareans found 16 cases of bladder injury and 4 cases
of ureteric injury, giving a rate of 0.27 per 1000 caesarean
sections. Rajasekar and Hall23 reported that all bladder injuries
were noted intraoperatively, whereas only 1 of the 4 ureteric
injuries were detected as it co-existed with a bladder injury.23
Other sources state that ureteric injuries are missed
intraoperatively in approximately 70% of cases.24
The ureters may be damaged in several ways but the
commonest during caesarean are transection and ligation (or
kinking) by a suture. Transection can occur when there is
extension of the uterine incision into the broad ligament. In
this situation, they are also at risk of inclusion within a suture
during attempts at haemostasis because of the close
proximity of the ureters to the uterine arteries.25 The
ureters are also at risk where they join the bladder and, in
this case, may be damaged as part of a concomitant bladder
injury or attempts to repair a bladder injury.23,26
Whereas bladder injury is usually obvious during caesarean
section, ureteric injury is not and there must be a high index
of suspicion to find it. If there is concern, a urologist should
be contacted. Intravenous injection of dye and transurethral
cystoscopy can be used to demonstrate ureteric patency.26
When not recognised intraoperatively, ureteric injury may
present in a number of ways depending on the injury,
location and length of time postoperatively. Bilateral
complete occlusion or transection of the ureters will result
in postoperative anuria. Other signs and symptoms include
fever, haematuria, flank pain, abdominal distension, sepsis/
peritonitis/ileus, or retroperitoneal urinoma formation.
There may be urinary leakage from the vagina suggesting
fistula formation or from the abdominal wound or drain
suggesting intra-abdominal urine collection.26 Renal function
testing may suggest renal failure due to obstructive
nephropathy in the case of occlusion or metabolite
reabsorption where there is transection. Conversely, it may
present much later with secondary hypertension because of
obstructive nephropathy.26
If ureteric injury is suspected postoperatively then imaging
should be done to confirm and identify the nature and site of
any injury. Renal ultrasound is useful for visualising the
kidneys and identifying hydronephrosis. It is noninvasive but
cannot confirm continuity of the ureter or identify the exact
level and nature of obstruction. CT with intravenous contrast
268
can assess patency and has the advantage over intravenous
urogram in that it images other pelvic organs in the case of
diagnostic uncertainty. Delayed sequences may be needed to
see if contrast is collecting outside the ureter. If diagnostic
uncertainty remains then cystoscopy with formal retrograde
ureterogram can be done, but this is more invasive than
either an intravenous urogram or CT.26
Management depends on the injury and location: partial
transection may be treated by ureteric stent placement,
complete transection may be managed by
ureteroneocystostomy (re-implantation of the proximal
ureter into the bladder) or ureteroureterostomy (re-
anastomosis of the cut ureter),27 and occlusion with a
suture may be treated by removal of the suture and/or
stenting of the ureter, if needed. A case series from Turkey
looked at ureteric injuries diagnosed late after caesarean
section and managed percutaneously.28 The average time to
recognition was 21 days but the maximum delay in diagnosis
was 8 months. They performed anterograde pyelography to
delineate the lesion, followed by percutaneous nephrostomy.
In cases of obstruction, they performed weekly pyelograms
through the nephrostomy and awaited dissolution of the
sutures. They also reported that five cases of partial
transection, including one of ureterovaginal fistula, were
treated entirely percutaneously. Overall 75% of ureteric
injuries were managed percutaneously.28
Bowel injury
Immediate bowel injury is a rare complication and the RCOG
consent advice does not list bowel injury as a serious risk, but
rather refers to the possibility of bowel repair as an additional
procedure.29 Compared with bladder injury, there is much
less published literature on intraoperative bowel injury. The
distended gravid uterus displaces the bowel from the
operative field at caesarean section; however, the bowel can
still be damaged in several ways. Loops of bowel may be
adherent to the anterior abdominal wall, particularly if there
has been a history of surgery via midline incision, and may be
damaged during peritoneal entry or if extensive division of
adhesions are required prior to delivery. After delivery, the
bowel can be damaged during closure. While the uterus is
being closed, particularly if there are angle extensions, it is
possible to include loops of bowel within the sutures,
posterior to the uterus. Exteriorisation of the uterus allows
direct visualisation of the posterior aspect of the uterus and
should be considered if there are significant extensions.
It is essential to diagnose bowel injury intraoperatively and
ask a surgeon to attend for the repair. These injuries may
often be treated with primary closure if small, even in
unprepared bowel, but if larger or multiple they may require
resection of the damaged bowel segment. It is vitally
important to avoid damaging the bowel with diathermy as
ª 2016 Royal College of Obstetricians and Gynaecologists

thermal injury may be difficult to spot and the patient may
present 48–72 hours later with bowel perforation secondary
to tissue necrosis.30
There is little specific literature on management of bowel
injury at caesarean. A case series of ten patients from 2011
looked at primary repair against colostomy and concluded
that primary repair should be attempted for all traumatic
colonic injuries and intraperitoneal rectal injuries. The causes
of bowel trauma in this case series were predominantly
penetrating abdominal trauma, so caution needs to be used
when considering generalisability to iatrogenic
surgical injury.31
Bowel injury not recognised intraoperatively will usually
present with signs and symptoms of intra-abdominal sepsis.
This may be delayed for several days in the case of
perforation following diathermy injury. CT imaging may be
undertaken and show extraluminal air and fluid, although
these may also be a normal finding in the immediate
postoperative period. Distended loops of bowel, evidence of
inflammation/abscess formation and, particularly,
extravasation of oral contrast material are much more
suggestive of gastrointestinal perforation.32 Re-operating in
the presence of peritonitis is much more likely to require
colostomy than if injuries are identified at the time of
primary surgery.
Postoperative ileus
Postoperative ileus refers to severe constipation and
intolerance of oral intake due to non-mechanical causes
after surgery. It may be a normal, physiological response to
abdominal surgery, but may also occur in patients after other
forms of surgery. The pathogenesis of postoperative ileus is
not fully understood and causation is likely to be
multifactorial.33 The incidence of ileus after gynaecological
procedures has been estimated to be 10–15% although there
is a paucity of specific data for caesarean section. A 2014
systematic review examining the role of chewing gum in
reducing postoperative ileus after caesarean section suggested
an incidence of approximately 12% in the control group and
that chewing gum may reduce the risk to 5%.33
Ileus presents with anorexia, nausea and vomiting, absence
of flatus, pain and distension worsening from time of
surgery. The symptoms are variable depending on the site of
bowel involved. Lower gastrointestinal involvement may
feature absence of flatus with minimal distension and
tolerance of oral intake whereas upper gastrointestinal
involvement may feature distension, vomiting and
intolerance of oral intake with the preservation of flatus.34
Intravenous fluid replacement, anti-emetics and the
limitation of oral intake are used to manage postoperative
ileus. Patients with significant distension, especially if
accompanied with intractable vomiting, may benefit from a
ª 2016 Royal College of Obstetricians and Gynaecologists
Field and Haloob
nasogastric tube. Renal function and electrolytes should be
checked and abnormalities corrected. Opiate analgesia, which
can impede bowel function, should be minimised.35
The main diagnostic challenge is excluding the unlikely
but more serious causes of bowel obstruction; these
include immediate postoperative adhesion formation,
intra-abdominal sepsis, Ogilvie syndrome, and
unrecognised intraoperative bowel injury. For patients
failing to improve with simple conservative measures or
who appear more unwell than expected for postoperative
ileus, an abdominal X-ray is a useful initial investigation.
Gas throughout the abdomen, including both large and
small bowel, is more suggestive of paralytic ileus, whereas
distended loops of small bowel with no gas in the colon is
more suggestive of a mechanical obstruction. X-ray allows
the caecal diameter to be measured if Ogilvie syndrome is
suspected. Similarly, a CT scan of the abdomen gives the
same information but will also show intra-abdominal
collections and show the obstruction transition point of
the bowel more precisely.35
Ogilvie syndrome
Ogilvie syndrome is defined as acute large bowel obstruction
without a mechanical cause.36 It is not specific to caesarean
section but can occur in any patient undergoing surgery and,
indeed, has been reported in nonsurgical patients with
serious underlying medical conditions. The exact
pathophysiology is unknown but it may be due to an
imbalance in the autonomic innervation of the distal colon
leading to atony and subsequent proximal dilatation. During
a caesarean section, Ogilvie syndrome may be caused by
damage to the sacral parasympathetic nerve supply, which
runs close to the cervix, vagina and broad ligament.36 The
classic presentation is progressive abdominal distension,
which may initially be painless and associated with varying
degrees of constipation. As the caecum becomes more
dilated, the pain worsens, localising to the right-hand side
with associated tachycardia. Eventually there is caecal
ischaemia, perforation and peritonitis.
There should be a high index of suspicion in postcaesarean
women with progressive abdominal distension. Initial
management is with intravenous fluids, analgesia,
correction of electrolyte imbalances, nasogastric tube
insertion and an abdominal X-ray. Early involvement of the
general surgical team and senior obstetrician is
recommended. Imaging usually shows grossly dilated loops
of large bowel, especially the caecum. It has been suggested
that for caecal diameters of less than 10–12 cm, conservative
management should be attempted with consideration of
intravenous neostigmine. For caecal diameters of greater than
10–12 cm, the patient should have urgent colonic
decompression with a rectal flatus tube. Most patients will
269
 Complications of caesarean section

recover quickly but if decompression fails or there is evidence

of peritonitis, laparotomy and bowel resection is required.36
Some case reports suggest earlier surgical intervention at
smaller caecal diameters but the key to management is
prompt recognition and general surgical input.37
The specific complications of caesarean section are
summarised in Table 1.
Caesarean section at full dilatation
There is evidence that the incidence of second stage caesarean
sections is increasing.38 These are associated with an increase
in maternal morbidity, including haemorrhage, wound
extension and visceral trauma.39 Similarly, there is a higher
risk of fetal trauma associated with difficulty in delivering a

Table 1. Complications occurring during or after caesarean section

Complication Incidence Avoidance Treatment

Postpartum Approx 5% 1. Antenatal diagnosis of abnormal 1. Uterotonic agents

haemorrhage placentation/fibroids, etc. 2. Prompt surgical repair
2. Meticulous surgical technique 3. Balloon tamponade
4. Compression sutures
5. Uterine devascularisation
6. Interventional radiology
7. Hysterectomy

Sepsis Wound: 6.8–9.7% 1. Antibiotics prior to skin incision 1. Antibiotics

Endometritis: 2. Vaginal decontamination 2. Radiological drainage
3.9–18.4% 3. Meticulous haemostasis 3. Wound exploration/debridement
4. Appropriate use of abdominal/wound 4. Re-laparotomy, debridement, wash-out
drains

Bladder injury Approx 0.1% 1. Careful peritoneal entry 1. Surgical repair

2. ?Avoiding bladder flap creation 2. Consider possibility of ureteric damage
3. Avoiding excessively low uterine incision 3. Bladder drainage
4. Cystogram 10–14 days later

Ureter injury Approx 0.4% 1. Correct for dextro-rotation prior to uterine 1. Urology opinion
incision 2. Ureteric occlusion:
2. Caution when repairing extensions and
operating near broad ligament i. Suture removal
3. Caution when repairing bladder injuries ii. Ureteric stenting
iii. Nephrostomy

3. Ureteric transection:

i. Re-anastomosis
ii. Re-implantation

Bowel injury ? 1. Careful peritoneal entry 1. General surgical assistance

2. General surgical assistance if extensive 2. Primary repair
previous surgery 3. Resection and stoma formation
3. ?Exteriorisation when suturing near
broad ligament

Postoperative ileus Approx 12% 1. Careful bowel handling 1. Exclusion of more serious pathology
2. ?Chewing gum postoperatively 2. IV fluid replacement
3. Correction of electrolytes
4. Anti-emetics
5. Gastric drainage
6. Minimise opiates

Ogilvie syndrome ? 1. As for postoperative ileus

2. Urgent surgical review
3. Consideration of neostigmine
4. Rectal flatus tube
5. Laparotomy

270 ª 2016 Royal College of Obstetricians and Gynaecologists


deeply impacted head. Fetal head lifting devices are under
evaluation and have been associated with statistically
significant reductions in operating time, incision to delivery
time and uterine extensions, although the evidence base is
limited.40 The use of such devices is not currently routine or
recommended outside of an audit or research trial.40
Complications of caesarean section in
resource-poor countries
Caesarean section rates have increased rapidly in many low- and
middle-income countries, a trend that might have serious effects
on maternal health, particularly physical and socioeconomic
consequences of caesarean section in resource-poor countries.
An analysis by Vogel et al.41 showed that caesarean section rates
in low human development index countries increased by 6%
between 2004–08 and 2010–11. A study carried out in Matlab,
Bangladesh used interviews with women and their families to
show that women were often poorly informed about the
indication and expected complications for their caesarean
section. In addition, women undergoing caesarean section
incurred high costs, leading to economic burdens on other
family members and a sense of blame directed at the
women themselves.42
Caesarean sections performed at regional hospitals may be
associated with higher rates of complications when compared
with tertiary centres. A cross-sectional study of all women
who fulfilled the World Health Organization (WHO) criteria
for maternal near-miss or death in Tanzania showed that
caesarean section complications were associated with 7.9% of
all maternal near-misses and 13% of maternal deaths. Life
threatening caesarean section complications were three times
higher (relative risk of 3.2, 95% CI 1.5–6.6) at the regional
hospital compared with the university hospital.43
The health systems in these countries need to be
strengthened to ensure that all women in genuine need of
life-saving obstetric surgery have a safe caesarean section
while mechanisms are developed to discourage excessive use,
which could result in added morbidity, no discernible
benefits and pose a financial burden in resource-
poor countries.44
Conclusion
Caesarean section is one of the most commonly performed
surgical procedures in the world. There are a variety of
complications that may be uncommon but potentially very
serious when they occur. Obstetricians must operate with a
meticulous surgical technique and retain a high index of
suspicion for complications, particularly visceral trauma, as
delayed recognition is associated with a significantly poorer
outcome. Most complications will be recognised at the
ª 2016 Royal College of Obstetricians and Gynaecologists
Field and Haloob
time of operation and are easily corrected either by
the operating surgeon or by seeking assistance from
other specialties.
Disclosure of interests
AF is the National Trainees’ Committee Representative for
Health Education East of England and also sits on the RCOG
Professional Development Committee.
Contribution of authorship
RH instigated, co-wrote and edited the article. AF researched,
co-wrote and edited the article.
References
1 Health & Social Care Information Centre. NHS Maternity Statistics - England,
2013-14. Leeds: hscic; 2015 [http://www.hscic.gov.uk/catalogue/
PUB16725].
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ª 2016 Royal College of Obstetricians and Gynaecologists