What are the possible post-operative complications of cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Answer

Postpartum endomyometritis 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. The postcesarean rate of endomyometritis can be decreased to approximately 5% with the use prophylactic antibiotics. [111, 112, 113, 13]

Major risk factors for endomyometritis 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.

After 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 débride 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. [112, 113]

With regard to vacuum-assisted closure in obese gravidas with wound disruption, level III evidence suggests that vacuum therapy can be included as an option for management of abdominal wounds, but evidence from randomized controlled trials in obese women undergoing cesarean delivery is not available. Research regarding the management of disrupted laparotomy wounds, overall, seems to support primary over delayed closure unless the wound is contaminated. Infected wounds should be opened and drained and antibiotic therapy should be added if cellulitis or systemic toxicity is present. [114]

Fascial dehiscence is an infrequent complication of a wound breakdown but constitutes a surgical emergency when it occurs. It develops 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, débrided, and reclosed in a sterile environment. [111, 112, 115]

The second most common etiology for postcesarean febrile morbidity is urinary tract infection (UTI). 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 UTIs is increased in patients with diabetes, those who have other comorbidities, and those who have a longer duration of use of the indwelling catheter. [112]

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 must be a priority. [111]

Thromboembolic complications are also increased in patients who have undergone a cesarean delivery. Approximately 0.5-1 in 500 pregnant women experience deep venous thrombosis (DVT). [116, 117] The risk for developing a thrombus is increased 3- to 5-fold with a cesarean delivery and in the postpartum period. [117] Other risks include obesity, advanced maternal age, higher parity, and poor postoperative ambulation.

In those with risk factors for thromboembolism, consider pneumatic compression stockings or, in patients with additional risk factors, low-molecular-weight heparin. If DVT is not treated, up to one quarter of patients will develop pulmonary emboli and 15% of these could be fatal. DVT is sometimes difficult to diagnose, and the first sign may be a pulmonary embolus. [118]

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. [119] Ultrasonography, pelvic computed tomography (CT) scanning, or magnetic resonance imaging (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. [120] 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.


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