Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Cesarean delivery: Postoperative issues

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


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: Surgical technique".)


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.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 01, 2017.
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 ©2017 UpToDate, Inc.
  1. Mhyre JM, DʼOria R, Hameed AB, et al. The maternal early warning criteria: A proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124:782.
  2. 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.
  3. 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.
  4. Griffiths R, Fernandez R. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev 2007; :CD004011.
  5. Marschall J, Carpenter CR, Fowler S, et al. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ 2013; 346:f3147.
  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. Pereira Gomes Morais E, Riera R, Porfírio GJ, et al. Chewing gum for enhancing early recovery of bowel function after caesarean section. Cochrane Database Syst Rev 2016; 10:CD011562.
  8. Weir LF, Nygaard IE, Wilken J, et al. Postoperative activity restrictions: Any evidence? Obstet Gynecol 2006; 107:305.
  9. 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.
  10. Minig L, Trimble EL, Sarsotti C, et al. Building the evidence base for postoperative and postpartum advice. Obstet Gynecol 2009; 114:892.
  11. Diegelmann RF, Evans MC. Wound healing: an overview of acute, fibrotic and delayed healing. Front Biosci 2004; 9:283.
  12. Evenson KR, Mottola MF, Owe KM, et al. Summary of international guidelines for physical activity after pregnancy. Obstet Gynecol Surv 2014; 69:407.
  13. Toon CD, Ramamoorthy R, Davidson BR, Gurusamy KS. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev 2013; :CD010259.
  14. Peleg D, Eberstark E, Warsof SL, et al. Early wound dressing removal after scheduled cesarean delivery: A randomized controlled trial. Am J Obstet Gynecol 2016; 215:388.e1.
  15. Toon CD, Sinha S, Davidson BR, Gurusamy KS. Early versus delayed post-operative bathing or showering to prevent wound complications. Cochrane Database Syst Rev 2013; :CD010075.
  16. Armson BA. Is planned cesarean childbirth a safe alternative? CMAJ 2007; 176:475.
  17. 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.
  18. 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.
  19. Creanga AA, Bateman BT, Butwick AJ, et al. Morbidity associated with cesarean delivery in the United States: Is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 2015; 213:384.e1.
  20. Glance LG, Dick AW, Glantz JC, et al. Rates of major obstetrical complications vary almost fivefold among US hospitals. Health Aff (Millwood) 2014; 33:1330.
  21. Hammad IA, Chauhan SP, Magann EF, Abuhamad AZ. Peripartum complications with cesarean delivery: A review of Maternal-Fetal Medicine Units Network publications. J Matern Fetal Neonatal Med 2014; 27:463.
  22. Carter EB, Temming LA, Fowler S, et al. Evidence-based bundles and cesarean delivery surgical site infections: A systematic review and meta-analysis. Obstet Gynecol 2017; 130:735.
  23. Temming LA, Raghuraman N, Carter EB, et al. Impact of evidence-based interventions on wound complications after cesarean delivery. Am J Obstet Gynecol 2017; 217:449.e1.
  24. 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.
  25. Ketcheson F, Woolcott C, Allen V, Langley JM. Risk factors for surgical site infection following cesarean delivery: A retrospective cohort study. CMAJ Open 2017; 5:E546.
  26. 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.
  27. Roberts S, Maccato M, Faro S, Pinell P. The microbiology of post-cesarean wound morbidity. Obstet Gynecol 1993; 81:383.
  28. Sarsam SE, Elliott JP, Lam GK. Management of wound complications from cesarean delivery. Obstet Gynecol Surv 2005; 60:462.
  29. Ueland K. Maternal cardiovascular dynamics. VII. Intrapartum blood volume changes. Am J Obstet Gynecol 1976; 126:671.
  30. 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.
  31. Oliphant SS, Bochenska K, Tolge ME, et al. Maternal lower urinary tract injury at the time of Cesarean delivery. Int Urogynecol J 2014; 25:1709.
  32. Phipps MG, Watabe B, Clemons JL, et al. Risk factors for bladder injury during cesarean delivery. Obstet Gynecol 2005; 105:156.
  33. Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.
  34. Clark SL, Christmas JT, Frye DR, et al. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014; 211:32.e1.
  35. LaRosa JA, Saywell RM Jr, Zollinger TW, et al. The incidence of adynamic ileus in postcesarean patients. Patient-controlled analgesia versus intramuscular analgesia. J Reprod Med 1993; 38:293.
  36. DiMatteo MR, Morton SC, Lepper HS, et al. Cesarean childbirth and psychosocial outcomes: A meta-analysis. Health Psychol 1996; 15:303.
  37. Clement S. Psychological aspects of caesarean section. Best Pract Res Clin Obstet Gynaecol 2001; 15:109.
  38. Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. Obstet Gynecol 2006; 108:885.
  39. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001; 97:439.
  40. 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.
  41. Royal College of Obstetricians and Gynaecologists (RCOG). Prevention and management of postpartum haemorrhage. www.rcog.org.uk (Accessed on January 20, 2012).
  42. 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.
  43. 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.
  44. Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006; 107:771.
  45. 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.
  46. 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.
  47. Odibo AO, Cahill AG, Stamilio DM, et al. Predicting placental abruption and previa in women with a previous cesarean delivery. Am J Perinatol 2007; 24:299.
  48. 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.
  49. Huikeshoven FJ, Dukel L. The bikini incision: Nice, but not without painful complications. Ned Tijdschr Geneeskd 1998; 142:1481.
  50. Tosun K, Schäfer G, Leonhartsberger N, et al. Treatment of severe bilateral nerve pain after Pfannenstiel incision. Urology 2006; 67:623.e5.
  51. Stulz P, Pfeiffer KM. Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch Surg 1982; 117:324.
  52. Sippo WC, Burghardt A, Gomez AC. Nerve entrapment after Pfannenstiel incision. Am J Obstet Gynecol 1987; 157:420.
  53. Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The Pfannenstiel incision as a source of chronic pain. Obstet Gynecol 2008; 111:839.
  54. Andolf E, Thorsell M, Källén K. Caesarean section and risk for endometriosis: A prospective cohort study of Swedish registries. BJOG 2013; 120:1061.
  55. 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.
  56. Blanco RG, Parithivel VS, Shah AK, et al. Abdominal wall endometriomas. Am J Surg 2003; 185:596.
  57. Bij de Vaate AJ, van der Voet LF, Naji O, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: Systematic review. Ultrasound Obstet Gynecol 2014; 43:372.
  58. Tulandi T, Agdi M, Zarei A, et al. Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009; 201:56.e1.
  59. Soltan MH, Al Nuaim L, Khashoggi T, et al. Sequelae of repeat cesarean sections. Int J Gynaecol Obstet 1996; 52:127.
  60. Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004; 87:227.
  61. Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007; 196:461.e1.
  62. Uygur D, Gun O, Kelekci S, et al. Multiple repeat caesarean section: Is it safe? Eur J Obstet Gynecol Reprod Biol 2005; 119:171.
  63. 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.
  64. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
  65. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
  66. Moraitis AA, Oliver-Williams C, Wood AM, et al. Previous caesarean delivery and the risk of unexplained stillbirth: Retrospective cohort study and meta-analysis. BJOG 2015; 122:1467.
  67. 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.
  68. 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.
  69. Smith GC, Wood AM, Pell JP, Dobbie R. First cesarean birth and subsequent fertility. Fertil Steril 2006; 85:90.
  70. Tollånes MC, Melve KK, Irgens LM, Skjaerven R. Reduced fertility after cesarean delivery: A maternal choice. Obstet Gynecol 2007; 110:1256.
  71. 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.
  72. Eijsink JJ, van der Leeuw-Harmsen L, van der Linden PJ. Pregnancy after caesarean section: Fewer or later? Hum Reprod 2008; 23:543.
  73. CORONIS collaborative group, Abalos E, Addo V, et al. Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial. Lancet 2016; 388:62.
  74. Levine LD, Sammel MD, Hirshberg A, et al. Does stage of labor at time of cesarean delivery affect risk of subsequent preterm birth? Am J Obstet Gynecol 2015; 212:360.e1.
  75. Wood SL, Tang S, Crawford S. Cesarean delivery in the second stage of labor and the risk of subsequent premature birth. Am J Obstet Gynecol 2017; 217:63.e1.
  76. Rutayisire E, Huang K, Liu Y, Tao F. The mode of delivery affects the diversity and colonization pattern of the gut microbiota during the first year of infants' life: a systematic review. BMC Gastroenterol 2016; 16:86.
  77. Sakwinska O, Foata F, Berger B, et al. Does the maternal vaginal microbiota play a role in seeding the microbiota of neonatal gut and nose? Benef Microbes 2017; 8:763.
  78. Moore HC, de Klerk N, Holt P, et al. Hospitalisation for bronchiolitis in infants is more common after elective caesarean delivery. Arch Dis Child 2012; 97:410.
  79. Black M, Bhattacharya S, Philip S, et al. Planned cesarean delivery at term and adverse outcomes in childhood health. JAMA 2015; 314:2271.
  80. Black M, Bhattacharya S, Philip S, et al. Planned repeat cesarean section at term and adverse childhood health outcomes: A record-linkage study. PLoS Med 2016; 13:e1001973.
  81. Bager P, Wohlfahrt J, Westergaard T. Caesarean delivery and risk of atopy and allergic disease: Meta-analyses. Clin Exp Allergy 2008; 38:634.
  82. Committee opinion no. 725. Summary: Vaginal seeding. Obstet Gynecol 2017; 130:1178.
  83. Haahr T, Glavind J, Axelsson P, et al. Vaginal seeding or vaginal microbial transfer from the mother to the caesarean-born neonate: A commentary regarding clinical management. BJOG 2017.