Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Cesarean delivery: Postoperative issues

INTRODUCTION

This topic will review the postoperative care of women who have undergone cesarean delivery and discuss potential sequelae of this procedure. Preoperative and intraoperative issues are discussed separately. (See "Cesarean delivery: Preoperative issues" and "Cesarean delivery: Technique".)

POSTOPERATIVE CARE

In the immediate postoperative period, the woman is monitored for evidence of uterine atony, excessive vaginal or incisional bleeding, and oliguria. Blood pressure is monitored to assess for hypo or hypertension, which could be signs of intraabdominal bleeding or preeclampsia, respectively.

Patient controlled opioid analgesia followed by oral nonsteroidal antiinflammatory drugs provides adequate pain relief for most women. (See "Anesthesia for cesarean delivery", section on 'Planning postcesarean analgesia'.)

There is no evidence that routine urine culture or a trial of catheter clamping is useful before removal of the bladder catheter [1,2].

The mother can be instructed in ways to hold her newborn to avoid contact with the incision; lying on her side or a 'football hold' may be used, or a pillow may be placed over the incision and under the infant so the direct contact with the incision is minimized. Heavy lifting and lifting from a squat position confer the greatest increases in intraabdominal pressure [3,4]. These activities should probably be minimized in the first one to two weeks of wound healing, although there are no data regarding the impact of various intraabdominal pressures on wound healing [5].

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2014. | This topic last updated: Apr 4, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Horowitz E, Yogev Y, Ben-Haroush A, et al. Urine culture at removal of indwelling catheter after cesarean section. Int J Gynaecol Obstet 2004; 85:276.
  2. Griffiths R, Fernandez R. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev 2007; :CD004011.
  3. Weir LF, Nygaard IE, Wilken J, et al. Postoperative activity restrictions: any evidence? Obstet Gynecol 2006; 107:305.
  4. Gerten KA, Richter HE, Wheeler TL 2nd, et al. Intraabdominal pressure changes associated with lifting: implications for postoperative activity restrictions. Am J Obstet Gynecol 2008; 198:306.e1.
  5. Minig L, Trimble EL, Sarsotti C, et al. Building the evidence base for postoperative and postpartum advice. Obstet Gynecol 2009; 114:892.
  6. Hsu YY, Hung HY, Chang SC, Chang YJ. Early oral intake and gastrointestinal function after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol 2013; 121:1327.
  7. Horowitz E, Yogev Y, Ben-Haroush A, et al. Routine hemoglobin testing following an elective Cesarean section: is it necessary? J Matern Fetal Neonatal Med 2003; 14:223.
  8. National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol 2006; 107:1386.
  9. Armson BA. Is planned cesarean childbirth a safe alternative? CMAJ 2007; 176:475.
  10. Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol 2007; 109:669.
  11. Alexander JM, Leveno KJ, Rouse DJ, et al. Comparison of maternal and infant outcomes from primary cesarean delivery during the second compared with first stage of labor. Obstet Gynecol 2007; 109:917.
  12. Leth RA, Møller JK, Thomsen RW, et al. Risk of selected postpartum infections after cesarean section compared with vaginal birth: a five-year cohort study of 32,468 women. Acta Obstet Gynecol Scand 2009; 88:976.
  13. Duff P. Pathophysiology and management of postcesarean endomyometritis. Obstet Gynecol 1986; 67:269.
  14. Owen J, Andrews WW. Wound complications after cesarean sections. Clin Obstet Gynecol 1994; 37:842.
  15. Olsen MA, Butler AM, Willers DM, et al. Risk factors for surgical site infection after low transverse cesarean section. Infect Control Hosp Epidemiol 2008; 29:477.
  16. Martens MG, Kolrud BL, Faro S, et al. Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases. J Reprod Med 1995; 40:171.
  17. Roberts S, Maccato M, Faro S, Pinell P. The microbiology of post-cesarean wound morbidity. Obstet Gynecol 1993; 81:383.
  18. Sarsam SE, Elliott JP, Lam GK. Management of wound complications from cesarean delivery. Obstet Gynecol Surv 2005; 60:462.
  19. Ueland K. Maternal cardiovascular dynamics. VII. Intrapartum blood volume changes. Am J Obstet Gynecol 1976; 126:671.
  20. Larsson C, Saltvedt S, Wiklund I, et al. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstet Gynecol Scand 2006; 85:1448.
  21. Rouse DJ, MacPherson C, Landon M, et al. Blood transfusion and cesarean delivery. Obstet Gynecol 2006; 108:891.
  22. American College of Obstetricians and Gynecologists. Lower urinary tract operative injuries. ACOG educational bulletin 238, American College of Obstetricians and Gynecologists, Washington, DC 1997.
  23. Phipps MG, Watabe B, Clemons JL, et al. Risk factors for bladder injury during cesarean delivery. Obstet Gynecol 2005; 105:156.
  24. Eisenkop SM, Richman R, Platt LD, Paul RH. Urinary tract injury during cesarean section. Obstet Gynecol 1982; 60:591.
  25. Rajasekar D, Hall M. Urinary tract injuries during obstetric intervention. Br J Obstet Gynaecol 1997; 104:731.
  26. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008; 179:1379.
  27. Niël-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev 2005; :CD005428.
  28. Pfefferkorn U, Lea S, Moldenhauer J, et al. Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infections: a prospective randomized trial. Ann Surg 2009; 249:573.
  29. Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG 2001; 108:56.
  30. Gherman RB, Goodwin TM, Leung B, et al. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol 1999; 94:730.
  31. Wechter ME, Pearlman MD, Hartmann KE. Reclosure of the disrupted laparotomy wound: a systematic review. Obstet Gynecol 2005; 106:376.
  32. Harris, RL, Magann, EF, Sullivan, DL, Meeks, GR. Extrafascial wound dehiscence: secondary closure with suture versus noninvasive adhesive bandage. J pelvic Surg 1995; 1:88.
  33. DiMatteo MR, Morton SC, Lepper HS, et al. Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol 1996; 15:303.
  34. Clement S. Psychological aspects of caesarean section. Best Pract Res Clin Obstet Gynaecol 2001; 15:109.
  35. Nielsen TF, Hökegård KH. Cesarean section and intraoperative surgical complications. Acta Obstet Gynecol Scand 1984; 63:103.
  36. Dessole S, Cosmi E, Balata A, et al. Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital. Am J Obstet Gynecol 2004; 191:1673.
  37. Gerber, AH. Int J Obstet Gynecol 1974; 12:46.
  38. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90:344.
  39. Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. Obstet Gynecol 2006; 108:885.
  40. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001; 97:439.
  41. Gerten KA, Coonrod DV, Bay RC, Chambliss LR. Cesarean delivery and respiratory distress syndrome: does labor make a difference? Am J Obstet Gynecol 2005; 193:1061.
  42. Schuitemaker N, van Roosmalen J, Dekker G, et al. Maternal mortality after cesarean section in The Netherlands. Acta Obstet Gynecol Scand 1997; 76:332.
  43. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology 1997; 86:277.
  44. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205:S2.
  45. Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery. Am J Obstet Gynecol 2011; 205:S11.
  46. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011; 205:262.e1.
  47. Royal College of Obstetricians and Gynaecologists (RCOG). Prevention and management of postpartum haemorrhage. www.rcog.org.uk (Accessed on January 20, 2012).
  48. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol 2001; 97:765.
  49. Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006; 107:771.
  50. Yang Q, Wen SW, Oppenheimer L, et al. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG 2007; 114:609.
  51. Jackson S, Fleege L, Fridman M, et al. Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Am J Obstet Gynecol 2012; 206:139.e1.
  52. National Institutes of Health Consensus Development Conference Statement. NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights. March 8–10, 2010.
  53. O'Neill SM, Kearney PM, Kenny LC, et al. Caesarean delivery and subsequent stillbirth or miscarriage: systematic review and meta-analysis. PLoS One 2013; 8:e54588.
  54. Bahtiyar MO, Julien S, Robinson JN, et al. Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997. Am J Obstet Gynecol 2006; 195:1373.
  55. Gurol-Urganci I, Bou-Antoun S, Lim CP, et al. Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis. Hum Reprod 2013; 28:1943.
  56. Smith GC, Wood AM, Pell JP, Dobbie R. First cesarean birth and subsequent fertility. Fertil Steril 2006; 85:90.
  57. Tollånes MC, Melve KK, Irgens LM, Skjaerven R. Reduced fertility after cesarean delivery: a maternal choice. Obstet Gynecol 2007; 110:1256.
  58. Murphy DJ, Stirrat GM, Heron J, ALSPAC Study Team. The relationship between Caesarean section and subfertility in a population-based sample of 14 541 pregnancies. Hum Reprod 2002; 17:1914.
  59. Eijsink JJ, van der Leeuw-Harmsen L, van der Linden PJ. Pregnancy after Caesarean section: fewer or later? Hum Reprod 2008; 23:543.
  60. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006; 107:1373.
  61. O'Neill SM, Khashan AS, Kenny LC, et al. Caesarean section and subsequent ectopic pregnancy: a systematic review and meta-analysis. BJOG 2013; 120:671.
  62. Huikeshoven FJ, Dukel L. [The bikini incision: nice, but not without painful complications]. Ned Tijdschr Geneeskd 1998; 142:1481.
  63. Tosun K, Schäfer G, Leonhartsberger N, et al. Treatment of severe bilateral nerve pain after Pfannenstiel incision. Urology 2006; 67:623.e5.
  64. Stulz P, Pfeiffer KM. Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch Surg 1982; 117:324.
  65. Sippo WC, Burghardt A, Gomez AC. Nerve entrapment after Pfannenstiel incision. Am J Obstet Gynecol 1987; 157:420.
  66. Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The Pfannenstiel incision as a source of chronic pain. Obstet Gynecol 2008; 111:839.
  67. Kim DH, Murovic JA, Tiel RL, Kline DG. Surgical management of 33 ilioinguinal and iliohypogastric neuralgias at Louisiana State University Health Sciences Center. Neurosurgery 2005; 56:1013.
  68. Andolf E, Thorsell M, Källén K. Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries. BJOG 2013; 120:1061.
  69. Gunes M, Kayikcioglu F, Ozturkoglu E, Haberal A. Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. J Obstet Gynaecol Res 2005; 31:471.
  70. Blanco RG, Parithivel VS, Shah AK, et al. Abdominal wall endometriomas. Am J Surg 2003; 185:596.
  71. Bij de Vaate AJ, van der Voet LF, Naji O, et al. The prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: a systematic review. Ultrasound Obstet Gynecol 2013.
  72. Tulandi T, Agdi M, Zarei A, et al. Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009; 201:56.e1.
  73. Soltan MH, Al Nuaim L, Khashoggi T, et al. Sequelae of repeat cesarean sections. Int J Gynaecol Obstet 1996; 52:127.
  74. Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004; 87:227.
  75. Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007; 196:461.e1.
  76. Uygur D, Gun O, Kelekci S, et al. Multiple repeat caesarean section: is it safe? Eur J Obstet Gynecol Reprod Biol 2005; 119:171.
  77. Andolf E, Thorsell M, Källén K. Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. Am J Obstet Gynecol 2010; 203:406.e1.
  78. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
  79. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
  80. Bates GW Jr, Shomento S. Adhesion prevention in patients with multiple cesarean deliveries. Am J Obstet Gynecol 2011; 205:S19.