What are the potential post-operative complications of a cesarean section (C-section)?

Post-Operative Complications of Cesarean Section

The most important post-operative complications of cesarean section to monitor for include venous thromboembolism (2.6-4.3 per 1000 births), wound infections, urinary tract infections, postpartum hemorrhage, and chronic wound pain (affecting 15.4% of women at 3-6 months). 1, 2

Immediate Complications (First 24-48 Hours)

Hemorrhage

• Excessive bleeding (>1000 ml) occurs in 5-10% of cesarean deliveries 3
• Primary causes: uterine atony, abnormal placentation, uterine trauma, and sepsis
• Management:
  • Obtain large-bore IV access
  • Consider warmed blood products
  • Monitor fibrinogen levels (normal pregnancy levels: 4-6 g/L)
  • For ongoing hemorrhage after 4 units of RBC, add FFP in a 1:1 ratio 2

Urinary Complications

• Urinary tract infection is one of the most common complications 1
• Indwelling catheters increase risk of UTI, urethral pain, and difficult voiding
• Blood-tinged urine may indicate:
  • Trauma from catheterization
  • Bladder injury (occurs in 0.1-0.5% of cesarean deliveries)
  • Post-surgical inflammation
  • Bladder flap hematoma 2

Wound Complications

• Subfascial and bladder flap hematomas:
  • Small hematomas (<4 cm): Conservative management with observation
  • Large hematomas (>5 cm): May require drainage or surgical intervention 2
• Wound infections: Can be reduced by using electric clippers rather than razors, chlorhexidine skin preparation, and pre-incision antibiotics 4

Early Complications (First Week)

Thromboembolism

• Pregnant and postpartum women have increased risk of venous thromboembolism 1
• Pooled incidence: 2.6 per 1000 cesarean births (up to 4.3 per 1000 with longer follow-up) 1
• Prevention:
  • Early mobilization for all patients
  • Mechanical methods (graduated compression stockings, intermittent pneumatic compression)
  • Pharmacologic methods (LMWH) for high-risk patients 1, 2

Infection

• Endometritis: Reduced by broad-spectrum antibiotic prophylaxis and removal of placenta by umbilical cord traction rather than manual extraction 4
• Wound infection: Proper skin preparation and antibiotic prophylaxis are essential

Medium-Term Complications (Weeks to Months)

Chronic Pain

• Pooled incidence of chronic wound pain:
  • 15.4% at 3-6 months postpartum
  • 11.5% at 6-11 months postpartum
  • 11.2% at 12+ months postpartum 1
• Prevalence ranges from 4% to 41.8% 1

Scar Complications

• Cesarean section scar defects: Prevalence ranges from 24% to 88% on ultrasonography 1
• Niche (cesarean section scar defect): 56-84% using contrast-enhanced sonohysterography and 24-70% using transvaginal sonography 1

Long-Term Complications

Future Pregnancy Risks

• Placenta accreta risk increases with each cesarean section:

  • After one cesarean: 12.9 per 10,000
  • After two cesareans: 41.3 per 10,000
  • After three cesareans: 78.3 per 10,000
  • After four cesareans: 217 per 10,000
  • After five or more cesareans: 230 per 10,000 1

• Uterine rupture:

  • Overall prevalence after cesarean: 22 per 10,000 births
  • With previous cesarean and labor: 35 per 10,000 births 1
  • Risk reduced by two-layer closure of uterine incision 4

Other Long-Term Complications

• Secondary infertility: Reported in 43% of women after cesarean delivery 1
• Pelvic organ prolapse: Prevalence of 1.9% among women with cesarean delivery only 1

Key Prevention Strategies

1. Thromboembolism prophylaxis: Early mobilization and appropriate use of mechanical/pharmacological prophylaxis based on risk assessment 1, 2

2. Infection prevention: Pre-incision antibiotics, proper skin preparation, and appropriate surgical technique 4

3. Urinary catheter management: Remove immediately after surgery when strict urine output monitoring isn't required 2

4. Proper surgical technique: Two-layer uterine closure to reduce future rupture risk; closure of deep subcutaneous layer when tissue is >2 cm thick 4

5. Early mobilization: Promotes recovery and reduces complication risks 2

By understanding and monitoring for these complications, healthcare providers can improve outcomes and quality of life for women undergoing cesarean delivery.