eMedicine Specialties > Obstetrics and Gynecology > Labor and Delivery

Cesarean Delivery: Treatment

Author: Saju Joy, MD, MS, Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
Coauthor(s): Stephen A Contag, MD, Instructor, Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Apr 2, 2009

Treatment

Medical Therapy

Many indications exist for performing a cesarean delivery. In those women who are having a scheduled procedure (ie, an elective or indicated repeat, for malpresentation or placental abnormalities), the decision has already been made that the alternate of medical therapy, ie, a vaginal delivery, is least optimal. For other patients admitted to labor and delivery, the anticipation is for a vaginal delivery. Every patient admitted in this circumstance is admitted with the thought of a successful vaginal delivery. However, if the patient's situation should change, a cesarean delivery is performed because it is believed that outcome for the fetus and/or the mother may be better.
 
If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for an external cephalic version is offered to try to convert the fetus to a vertex lie, thus allowing an attempt at a vaginal delivery. An external cephalic version is usually attempted at 36-38 weeks with studies underway to establish the use of performing external cephalic version at 34 weeks’ gestational age. Ultrasonography is performed to confirm a breech presentation. If the fetus is still in a nonvertex presentation, an intravenous line is started and the baby is monitored with an external fetal heart rate monitor prior to the procedure to confirm well being.
 
With a reassuring fetal heart rate tracing, the version is attempted. An external cephalic version involves trying to externally manipulate the fetus into a vertex presentation. This is accomplished with ultrasonographic guidance to ascertain fetal lie. An attempt is made to manipulate the fetus through either a "forward roll" or "backward roll." The overall chance of success is approximately 60%.50 Some practitioners administer an epidural to the patient prior to the attempted version, and others may give the patient a dose of subcutaneous terbutaline (a beta-mimetic used for tocolysis) just prior to the attempt.
 
Factors that influence the success of an attempted version include multiparity, a posterior placenta, and normal amniotic fluid with a normally grown fetus. Also, to be a candidate, a patient must be eligible for an attempted vaginal delivery. Relative contraindications include poor fetal growth or the presence of congenital anomalies. Risks of an external cephalic version include rupture of membranes, labor, fetal injury, and the need for an emergent cesarean delivery due to placental abruption. A recent review reported a severe complication rate of 0.24% and a cesarean section rate secondary to complications of 0.34%.50
 
If the version is successful, the patient is placed on a fetal monitor in close proximity to the labor and delivery unit or in the labor and delivery unit itself. If fetal heart rate testing is reassuring, either the patient is discharged to await spontaneous labor or she is induced if the fetus is of an appropriate gestational age and/or the patient has a favorable cervix.

Surgical Therapy

See Intraoperative details.

Preoperative Details

On average, patients are asked not to eat anything for 12 hours prior to the procedure, which exceeds current guidelines.51 The guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal.52 After arrival, an intravenous line is placed and IV fluids are infused. Preoperative lab samples are drawn. If a difficult procedure is anticipated with an increased risk for blood loss, cross-matched blood should be available for the start of the procedure. Intravenous fluid consists of either lactated Ringer solution or saline with 5% dextrose. The patient is placed on an external fetal monitor, and should be evaluated by the surgeon and the anesthesiologist.
 
The anesthesiologist will review regional anesthetic techniques. Regional anesthesia is used for 95% of planned cesarean deliveries in the United States. The 3 main regional anesthetic techniques are spinal, epidural, and combined spinal epidural.53 Every patient is evaluated for general anesthesia in case an emergency should arise and establishment of an airway becomes necessary. A review by Afolabi et al found that patients undergoing local anesthetic techniques were found to have a significantly lower difference between pre- and postoperative hematocrit levels when compared with patients undergoing general anesthesia. Women having either an epidural anesthesia or spinal have a lower estimated maternal blood loss.54
 
A blood pressure cuff is placed. Monitors are also placed to allow the patient's blood pressure, pulse, and oxygen saturation to be monitored prior to administering anesthesia through the initial postoperative period in the recovery room.
 
Prior to surgery, a Foley catheter is placed so that the bladder can be drained during the procedure and urine output can be monitored to help evaluate fluid status. After regional anesthesia, patients are unable to void spontaneously for as long as 24 hours.
 
Prior to anesthesia, the surgeon should evaluate the site of the intended skin incision. The intended area does not need to be shaved automatically unless the hair will interfere with the re-approximation of the skin edges. If the hair is to be shaved, it should be shaved immediately prior to the surgery.55 Clipping has been shown to be as effective, without the risk of cutting the skin associated with shaving and does not increase the risk of wound infections.56
 
After placement of the regional anesthetic, monitor the fetus until an adequate surgical level has been achieved. When the level of anesthesia is adequate, the skin can be prepared with either an iodine scrub or with 4% chlorhexidine. Prior to making the initial incision, grasp the patient's skin bilaterally with an instrument such as an Allis clamp at the level of and above the incision to confirm anesthesia up to the level of T-4. This ensures that the anesthetic level is appropriate. The dermatomal level of anesthesia required for cesarean delivery is higher than that required for labor analgesia. A sensory block to the 10th thoracic dermatome is sufficient to achieve analgesia for labor, but for cesarean, the anesthetic level must be extended cephalad to at least the fourth thoracic dermatome to prevent nociceptive input from the peritoneal manipulation.

Prior to beginning the surgery, inform the nursery so that a member of the nursery staff can be present to evaluate the baby after delivery and resuscitate as necessary.
 
In patients who require a cesarean delivery secondary to a problem arising during labor, the same steps as above are followed. The only major variation occurs if a patient requires general anesthesia prior to the procedure. In that situation, prior to intubation, the patient should be prepped and draped and the surgical team should be ready to begin as soon as the patient's airway is secured.

Intraoperative Details

As with any procedure, take care to avoid injury to adjacent organs. Potential complications include bladder or bowel injury. If a cystotomy or bowel injury is suspected, it should be evaluated thoroughly after the baby is delivered and hemostasis of the uterus is achieved.
 
The anesthesiologist monitors the patient's vital signs and tracks fluid intake and urine output. The average blood loss associated with a cesarean delivery is approximately 1000 mL.57 A patient at term will have up to a 50% expansion in their blood volume and can lose up to 1500 mL without showing any change in their vital signs. If a significant blood loss is encountered or anticipated, assess the hemoglobin level and cross-match blood.
 
Abdominal incision
 
One option is to use a midline infraumbilical incision to enter the peritoneal cavity. This incision provides quicker access to the uterus. In pregnancy, entry is commonly enhanced by diastasis of the rectus muscles. This incision is associated with less blood loss, easier examination of the upper abdomen, and easy extension cephalad around the umbilicus. If a patient is anticipated to have significant intra-abdominal adhesions from prior surgeries, a vertical incision may provide easier access into the abdomen, with better visualization. Upon reaching the rectus sheath, either the rectus sheath can be incised with a scalpel for the entire length of the incision or a small incision in the fascia can be made with a scalpel and then extended superiorly and inferiorly with scissors. Then, the rectus muscles (and pyramidalis muscles) are separated in the midline by sharp and blunt dissection. This act exposes the transversalis fascia and the peritoneum.
 
The peritoneum is identified and entered at the superior aspect of the incision to avoid bladder injury. Prior to entering the peritoneum, care is taken to avoid incising adjacent bowel or omentum. Once the peritoneal cavity is entered, the peritoneal incision is extended sharply to the upper aspect of the incision superiorly and to the reflection over the bladder inferiorly.
 
Most commonly, a transverse incision through the lower abdomen is made. The incision is a Maylard, Joel Cohen, or, more commonly, a Pfannenstiel incision. Transverse incisions take slightly longer to enter the peritoneal cavity, are usually less painful, have been associated with a smaller risk of developing an incisional hernia, are preferred cosmetically, and can provide excellent visualization of the pelvis.
 
The Pfannenstiel incision is curved slightly cephalad at the level of the pubic hairline. The incision extends slightly beyond the lateral borders of the rectus muscle bilaterally and is carried to the fascia. Then, the fascia is incised bilaterally for the full length of the incision. Then, the underlying rectus muscle is separated from the fascia both superiorly and inferiorly with blunt and sharp dissection. Clamp and ligate any blood vessels encountered. The rectus muscles are separated in the midline, and the peritoneum is entered.
 
A Maylard incision is made approximately 2-3 cm above the symphysis and is quicker than a Pfannenstiel incision. It involves a transverse incision of the anterior rectus sheath and rectus muscle bilaterally. Identify and possibly ligate the superficial inferior epigastric vessels (located in the lateral third of each rectus). For most cesarean deliveries, only the medial two thirds of each rectus muscle usually needs to be divided. If more than two thirds of the rectus muscle is divided, identify and ligate the deep inferior epigastric vessels. The transversalis fascia and peritoneum are identified and incised transversely.
 
The Joel Cohen incision is a straight transverse incision made 3 centimeters below the level of a straight line joining the anterosuperior iliac spines. The skin incision is made and carried down to the anterior sheath of the rectus fascia. A 3-4 cm incision is made in the fascia and bluntly opened by stretching in a craniocaudal fashion. The rectus muscles are retracted laterally and the parietal peritoneum is bluntly opened by digital dissection. The peritoneum is then retracted cephalocaudally to avoid injury to the bladder. Transverse incisions are associated with less blood loss, shorter operating time, reduced time to oral intake, less risk of fever, shorter duration of postoperative pain, lower analgesic requirements, and shorter time from skin incision to birth of the baby.58,59
 
No evidence reports an advantage of electrocautery over sharp knife dissection or digital dissection of the subcutaneous tissues, or  whether sharp or blunt retraction of the fascial tissues is preferable. Blunt dissection tends to be associated with reduced blood loss.60
 
The Maylard incision with transection of the rectus muscles is associated with increased blood loss.61
 
Uterine incision
 
Upon entering the peritoneal cavity by blunt or sharp dissection and blunt extension, inspect the lower abdomen. The uterus is palpated and is commonly found to be dextrorotated such that the left round ligament is more anterior and closer to the midline. Evidence suggests that development of a bladder flap is not always necessary, especially in the nonlabored patient.62 When it is created, dissect the bladder free of the lower uterine segment. Grasp the loose uterovesical peritoneum with forceps, and incise it with Metzenbaum scissors. The incision is extended bilaterally in an upward curvilinear fashion. The lower flap is grasped gently, and the bladder is separated from the lower uterus with blunt and sharp dissection. A bladder blade is placed to both displace and protect the bladder inferiorly and to provide exposure for the lower uterine segment (the least contractile portion of the uterus).
 
One of essentially 2 incisions can be made on the uterus, either a transverse (Monroe-Kerr) or vertical (Kronig or DeLee) incision. The decision for the type of incision is based on several factors, including fetal presentation, gestational age, placental location, and presence of a well-developed lower uterine segment. The choice of incision must allow enough room to deliver the fetus without risking injury (either tearing or cutting) to the uterine arteries and veins that are located at the lateral margins of the uterus.
 
In more than 90% of cesarean deliveries, a low transverse (Monroe-Kerr) incision is made. The incision is made 1-2 cm above the original upper margin of the bladder with a scalpel. The initial incision is small and is continued into the uterine wall until either the fetal membranes are visualized or the cavity is entered (take care to not injure the underlying fetus especially in well-labored patients with thinned out lower uterine segments).
 
The incision is extended bilaterally and slightly cephalad. The incision can be extended with either sharp dissection or blunt dissection (usually with the index fingers of the surgeon). Blunt dissection is associated with decreased blood loss but has the potential for unpredictable extension, and care should be taken to avoid injury to the uterine vessels.63,64 Uterine and vaginal extensions after a low transverse incision are more common after prolonged second stage of labor.65 The presenting part of the fetus is identified, and the fetus is delivered either as a vertex presentation or as a breech. With a low transverse incision, the risk for uterine rupture in subsequent pregnancies is approximately 0.5-1%, and patients can be counseled about the safety of an attempted trial of labor and vaginal birth.46
 
In some instances, a vertical incision is used. A vertical incision may be used if the lower segment is not well developed (ie, narrow), if an anterior placenta previa is present, or if the fetus is in a transverse lie or in a preterm nonvertex presentation. Again, the bladder has been dissected inferiorly to expose the lower segment, and the bladder blade has been placed.
 
The vertical incision is initiated with a scalpel in the inferior portion of the lower uterine segment. Care is taken to avoid injury to the underlying fetus, and the incision is carried into the uterus until the cavity is entered. When the cavity is entered, the incision is extended superiorly with sharp dissection. The fetus is identified and delivered. Note the extent of the superior portion of the uterine incision.
 
If the incision is confined to the lower uterine segment, it is considered a low vertical incision and patients can be counseled for a trial of labor and vaginal delivery in subsequent pregnancies. With a true low vertical incision, the risk of uterine rupture with a trial of labor is similar to that associated with a low transverse incision, with most recent reports finding a risk for uterine rupture of less than 1.5%.46 If the incision should be either extended into the contractile portion of the uterus or is made almost completely in the upper contractile portion, the risk of uterine rupture in future pregnancies is 4-10% and patients are counseled to undergo a repeat cesarean delivery with all subsequent pregnancies.46
 
A vertical incision may also be considered in those cases where a hysterectomy may be planned in the setting of a placenta accreta or if the patient has a coexisting cervical cancer for which a hysterectomy would be the appropriate treatment. A vertical incision is associated with increased blood loss and longer operating time (takes longer to close) with less risk of injury to the uterine vessels than a low transverse incision.
 
Delivery
 
Two important aspects of the delivery are the incision to delivery time, especially in previously compromised fetuses and delivery of the impacted fetal head. Longer incision to delivery times are associated with worsening neonatal outcomes.66 The impacted fetal head can be delivered either through pushing the head up from the vagina and elevating it up through the incision or by pulling it up as if it were a breech delivery. This may require extending the incision to make room to maneuver.67 After the fetus is delivered, the umbilical cord is doubly clamped and cut. Blood is obtained from the cord for fetal blood typing, and a segment of cord is placed aside for obtaining blood gas results if a concern exists regarding fetal status.

Following delivery, oxytocin (20 U) is placed in the intravenous fluid to increase contractions of the uterus. The placenta is usually delivered manually. Awaiting spontaneous delivery of the placenta with gentle traction is more time consuming but is associated with decreased blood loss, lower risk of endometritis, and lower maternal exposure to fetal red blood cells, which can be important to Rh-negative mothers delivering an Rh-positive fetus.68,69
 
A single dose of ampicillin or a first-generation or second-generation cephalosporin is appropriate and should be given within 30 minutes of skin incision.70,71 If the surgery is prolonged, a second dose can be administered every 2 hours to maintain adequate serum concentrations. If the patient has chorioamnionitis, broader-spectrum antibiotics, such as gentamicin and clindamycin or a penicillin with a beta-lactamase inhibitor such as piperacillin-tazobactam are indicated and should be continued in the postoperative period until the patient is afebrile. If methicillin-resistant Staphylococcus epidermidis (MRSA) is suspected as a pathogen, especially in abdominal wall infections, vancomycin will need to be added.
 
Repair of the uterine incision
 
Repair of the uterus can be facilitated by manual delivery of the uterine fundus through the abdominal incision. Externalizing the uterine fundus facilitates uterine massage, the ability to assess whether the uterus is atonic, and the examination of the adnexa.72
 
The uterine cavity is usually wiped clean of all membranes with a dry laparotomy sponge. Typically, a clamp is placed at the angles of the uterine incision. The incision is inspected for other bleeding vessels, and any extensions of the incision are evaluated. Inspect the bladder and lower segment inferior to the incision.
 
Repair of a low transverse uterine incision can be performed in either a 1-layer or 2-layer fashion with zero or double-zero chromic or Vicryl suture. The first layer should include stitches placed lateral to each angle, with prior palpation of the location of the lateral uterine vessels. Most physicians use a continuous locking stitch. If the first layer is hemostatic, a second layer (Lembert stitch), which is used to imbricate the incision, does not need to be placed. A large prospective study has shown no increase in postoperative complications with a 1-layer versus 2-layer closure. Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss, duration of the operative procedure, and presence of postoperative pain.64 Most studies have not demonstrated any advantage of 2-layer closure compared with 1-layer closure in decreasing the rate of uterine rupture in a subsequent pregnancy.73,74 Atleast1studyreporteda4-foldincrease in the risk of uterine rupture when comparing 2- to 1-layer closure.75,76
 
Closure of a vertical incision usually requires several layers because the incision is through a thicker portion of the uterus. Again, a heavy suture material is used, and usually the first layer closes the inner half of the incision, with a second and possibly third layer used to close the outer half and serosal edges. The extent of a vertical uterine incision impacts how a patient should be counseled regarding future pregnancies.
 
When the uterus is closed, attention must be paid to its overall tone. An atonic uterus can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on oxytocin augmentation for a prolonged period. If the uterus does not feel firm and contracted with massage and intravenous oxytocin, consider intramuscular injections of prostaglandin (15-methyl-prostaglandin, Hemabate) or methyl-ergonovine, and repeat as appropriate.
 
Continued closure
 
If the uterine incision is hemostatic, the uterine fundus is replaced into the abdominal cavity (unless a concurrent tubal ligation is to be performed). The incision is re-inspected for hemostasis, and the bladder flap is also inspected. The paracolic gutters are visualized, and any blood clots are removed with laparotomy sponges. The vesicouterine peritoneum and parietal peritoneum can be reapproximated with a running chromic stitch or synthetic monofilament stitch. Although many surgeons perform abdominal irrigation, this does not appear  advantageous.77 Many physicians prefer to not close the peritoneum because these surfaces reapproximate within 24-48 hours and can heal without scar formation.78 Furthermore, the rectus muscles to do not need to be reapproximated.
 
The subfascial and muscle tissue is inspected for bleeding, and, if hemostatic, the fascia is closed. The fascia can be closed with a running nonlocking stitch, and synthetic braided or monofilament sutures are preferred over chromic sutures. Chromic sutures do not maintain their tensile strength as long or as predictably as synthetic material. If the patient is at risk for poor wound healing (eg, those with chronic steroid use), then a delayed absorbable or permanent suture can be used. Place stitches at approximately 1-cm intervals and more than 1 cm away from the incision line.
 
The subcutaneous tissue should be inspected for hemostasis and can be irrigated according to physician preference. The subcutaneous tissue usually does not have to be reapproximated, but patients with subcutaneous depth greater than 2 cm may benefit from subcutaneous tissue closure.79 Placement of drains does not appear to aid in decreasing the risk of surgical site infection.80 The skin edges can be closed either with a subcuticular stitch or with staples (removed 3 or 4 d postoperatively). 

In a randomized controlled trial, Rousseau et al compared postoperative pain according to method of skin closure after a cesarean delivery. The authors found that in the staple group, as compared with the subcuticular sutures group, postoperative pain was significantly less and operative time was shorter. They concluded that staples should be the skin closure of choice for elective term cesareans.81

Postoperative Details

In the recovery room, vital signs are taken every 15 minutes for the first 1-2 hours, and urine output is monitored on an hourly basis. In addition to routine assessment, palpate the fundus to ensure that it feels firm. Pay attention to the amount of vaginal bleeding.
 
If the patient had regional anesthesia, they usually receive a long-acting analgesic with the regional anesthetic. Therefore, pain control is usually not an issue in the first 24 hours. If a patient did not receive a long-acting analgesic or had general anesthesia, administer narcotics either intramuscularly or intravenously (on schedule or with a basal rate supplemented with patient-controlled boluses). When the patient is tolerating liquids, administer narcotics orally as needed.
 
When patients recover sensation after a regional anesthetic and vital signs have been stable with minimal vaginal bleeding, they can be taken to their room. The patient should have vital signs taken every hour for at least the first 4 hours and, again, pay attention to urine output.
 
Overall, a patient should receive approximately 3-4 L of intravenous fluid from initiation of the intravenous line through the first 24 hours. The patient can be started on clear liquids 12-24 hours after an uncomplicated procedure, and diet can be advanced accordingly. When the patient is able to tolerate good oral intake, the intravenous fluids can be stopped.
 
The bladder catheter can be removed 12-24 hours postoperatively once the patient is ambulatory. If the patient is unable to void in 6 hours, consider replacing the Foley for an additional 12-24 hours.
 
On the first postoperative day, encourage the patient to ambulate. Increase ambulation every day as tolerated by the patient. The dressing can be removed 12-24 hours after surgery and can be left open after that time. Typically, the blood count is checked 12-24 hours after surgery, or sooner if a greater than average blood loss has occurred.
 
If a patient plans to breastfeed, this can be initiated within a few hours after delivery. If a patient plans to bottle feed, a tight bra or breast binder should be used in the postoperative period.
 
If the patient has recovered well postoperatively, she can be discharged safely 3-4 days after surgery. If staples were used to approximate the skin, remove them prior to discharge. If the patient has had a vertical skin incision or is at risk for poor healing (eg, diabetes or long-term steroid use), the physician may elect to keep the staples in for 2-3 extra days and have the patient return to the office at that time.
 
Prior to discharge, a discussion about contraception should take place. Stress that even if a mother is breastfeeding, she still can conceive. Ask patients to refrain from intercourse for 4-6 weeks postpartum.

Follow-up

After a cesarean delivery, the patient can be observed as a patient who delivered vaginally. The normal recommendation is to have the patient make a follow-up appointment 4-6 weeks after delivery. If bleeding has stopped, a repeat Papanicolaou test is customary. During this visit, review any notable findings from the surgery and discuss delivery options for future pregnancies.

Complications

Compared with a vaginal delivery, maternal mortality and especially morbidity is increased with cesarean delivery to approximately twice the rate after a vaginal delivery.46 The overall maternal mortality rate is 6-22 deaths per 100,000 live births, with approximately one third to one half of maternal deaths after cesarean delivery being directly attributable to the operative procedure itself. Part of this increase in mortality is that associated with a surgical procedure and, in part, related to the conditions that may have led to needing to perform a cesarean delivery.
 
Major sources of morbidity and mortality can be related to sequelae of infection, thromboembolic disease, anesthetic complications, and surgical injury.
 
Intraoperative complications

  • Uterine lacerations: Uterine lacerations, especially of the lower uterine segment, are more common with a transverse uterine incision. These lacerations can extend laterally or inferiorly. They are repaired easily. Take care to identify the uterine vessels when repairing lateral extensions, and, when repairing inferior extensions, the surgeon needs to think about the ureters. If the laceration extends into the broad ligament, strongly consider opening the broad ligament medial to the ovaries and identifying the course of the ureters. 
  • Bladder injury: This is an infrequent complication. It is more common with transverse abdominal incisions and in repeat cesarean deliveries. The bladder most commonly is injured when entering the peritoneal cavity or when separating the bladder from the lower uterine segment. Bladder injury has been reported to occur in more than 10% of uterine ruptures and in approximately 4% of cesarean hysterectomies. If a possibility exists that a cesarean hysterectomy may be performed, mobilize the bladder inferiorly as well as possible when dissecting it free of the lower uterine segment. If the dome of the bladder is lacerated, it can be repaired simply with a 2-layer closure of 2-0 or 3-0 chromic sutures, with the Foley catheter left in place for a few extra days. If the bladder is injured in the region of the trigone, consider ureteral catheterization with possible assistance from a urologist or gynecological surgeon. 
  • Ureteral injury: Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies. It is most likely to occur when repairing extensive lacerations of the uterus. Ureteral injury, most commonly occlusion or transection, is usually not recognized during the time of the operation. 
  • Bowel injury: Bowel injuries occur in less than 0.1% of all cesarean deliveries. The most common risk factor for bowel injury at the time of cesarean delivery is adhesions from prior cesarean deliveries or prior bowel surgery. If the bowel is adherent to the lower portion of the uterus, dissect it sharply. Injuries to the serosa can be repaired with interrupted silk sutures. If the injury is into the lumen, perform a 2-layer closure. The mucosa can be closed with interrupted 3-0 absorbable sutures placed in a transverse fashion for a longitudinal injury. For multiple injuries and injury to the large intestine, consider intraoperative consultation with a general surgeon or gynecologic oncologist. 
  • Uterine atony: Uterine atony is another intraoperative complication that can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on oxytocin augmentation for a prolonged period. When the uterus is closed, attention must be paid to its overall tone.82  

Postoperative complications 

  • Postpartum endomyometritis: This is increased significantly in patients who have had a cesarean delivery. The rate of endomyometritis is up to 20-fold higher than with a vaginal delivery. Major risk factors include whether the cesarean delivery was the intended (primary) procedure and the socioeconomic status of the patient. Other major risk factors include duration of membrane rupture, duration of labor, number of pelvic examinations, length of time with internal fetal monitors in place, and the presence of chorioamnionitis prior to initiating cesarean delivery. Blood cultures are positive in approximately 10% of patients with postoperative febrile morbidity, and broad-spectrum antibiotics should be used. The postcesarean rate of endomyometritis can be decreased to approximately 5% with the use prophylactic antibiotics.83,84,85,86
  • Wound infection: Following a cesarean delivery, the risk of a wound infection ranges from 2.5% to higher than 15%. Risk factors are similar to those noted for endomyometritis, with the lowest risk associated with those having a planned cesarean delivery. If chorioamnionitis is present at the time of the procedure, the risk for a wound infection can be as high as 20%. If a wound infection is suspected, open, irrigate, and debride the incision. Then, the open wound can be packed and cleaned several times a day. The wound can be allowed to heal by secondary intention, or, when it has begun to granulate, it can be closed.84,85  
  • Fascial dehiscence: An infrequent but emergent complication of a wound breakdown is a fascial dehiscence. It occurs in approximately 5% of patients with a wound infection and is suggested when excessive discharge from the wound is present. If a fascial dehiscence is observed, the patient should be taken immediately to the operating room where the wound can be opened, debrided, and reclosed in a sterile environment.83,84,87  
  • Urinary tract infections: The second most common etiology for postcesarean febrile morbidity is urinary tract infections. The incidence ranges from 2-16%, and the process of placing an indwelling catheter for the surgery is a risk factor in itself. The incidence of urinary tract infections is increased in patients with diabetes, those who have other comorbidity, and those who have a longer duration of use of the indwelling catheter.84  
  • Bowel function: Postoperatively, some patients may experience a slow return of bowel function. Postoperative narcotics may delay return of normal bowel function in a few patients. Most respond to conservative therapy, but a small portion may require decompression. In those with a slow return of bowel function, assessment of fluid and electrolyte status needs to be a priority.83  
  • Thromboembolic complications: These are also increased in the patient who has undergone a cesarean delivery. Approximately 0.5-1 in 500 pregnant women experience a deep venous thrombosis.88,89 The risk for developing a thrombus is increased 3- to 5-fold with a cesarean delivery and in the postpartum.89 Other risks include obesity, advanced maternal age, higher parity, and poor postoperative ambulation. In those with risk factors, consider pneumatic compression stockings or low molecular weight heparin among a patients with additional risk factors. If a deep venous thrombosis is not treated, up to one quarter of patients will develop pulmonary emboli and 15% of these could be fatal. A deep venous thrombosis is sometimes difficult to diagnose, and the first sign may be a pulmonary embolus.90  
  • Pelvic thrombophlebitis: Another infection-related complication of a cesarean delivery is septic pelvic thrombophlebitis. As many as 2% of patients with an endomyometritis or wound infection can develop this complication, and it is largely a diagnosis of exclusion. Suspect this diagnosis if a patient fails to respond initially to broad-spectrum antibiotics. Physical examination may detect a tender cordlike mass lateral to the uterus.91 Ultrasonography, pelvic CT scan, or MRI may aid in the diagnosis. Some authors advocate placing patients on therapeutic heparin along with continuing broad-spectrum antibiotics; however, this treatment has been questioned.92 The length of adequate treatment once a patient has defervesced is subject to debate (anywhere from 48-h afebrile to a total of 7-10 d of treatment). After completing the desired treatment course, patients do not need to be anticoagulated further.

More on Cesarean Delivery

Overview: Cesarean Delivery
Workup: Cesarean Delivery
Treatment: Cesarean Delivery
Follow-up: Cesarean Delivery
References
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References

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Further Reading

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Keywords

caesarean section, caesarean birth, cesarean section, C section, cesarean birth, vaginal delivery, childbirth, parturition, delivery, birthing, laparotomy, hysterotomy, low transverse incision, classical incision, vertical incision

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Contributor Information and Disclosures

Author

Saju Joy, MD, MS, Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
Saju Joy, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Contag, MD, Instructor, Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
Stephen A Contag, MD is a member of the following medical societies: American Institute of Ultrasound in Medicine and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jordan G Pritzker, MD, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard S Legro, MD, Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center
Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Vice Chair for Research and Education, Dept of OB/GYN, Tufts Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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