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Clinical Summary

Nearly one in four births are by cesarean section in the United States. As with any major surgery, there are several potential complications related to this procedure. For the mother, immediate complications include hemorrhage, uterine atony, and damage to the uterus and other abdominal organs. Immediately postoperatively, problems with the wound (infection and dehiscence), endometritis, and sepsis are possible. Complications with future pregnancies are long-term concerns. Patients may present to the ED with complaints of problems with the wound (bleeding or purulent discharge), erythema, tenderness, or dehiscence or with signs of pelvic infection or sepsis (fever, hypotension, pelvic pain, purulent vaginal discharge, or increased bleeding).

Management and Disposition

Management of postoperative complications of cesarean section should involve gynecologic consultation in most cases and is dependent on the specific complication. Controlled minor bleeding or local wound infection can be addressed in the ED with close gynecology follow-up. For significant bleeding, place two large-bore IVs, control bleeding with pressure, and prepare blood products for transfusion as needed for blood loss. Exquisite uterine tenderness accompanied by fever and heavy vaginal bleeding and/or purulent discharge is concerning for endometritis. Suspected endometritis or puerperal sepsis should prompt obtaining blood cultures, fluid resuscitation, and empiric antibiotic administration. Wound dehiscence ranges from superficial with only dermal and epidermal involvement to complete with extravasation of abdominal contents. Immediate gynecologic consultation is indicated for any dehiscence beyond superficial tissues. If bowel or other organs are visible, they should be inspected for signs of strangulation/ischemia (pale or dusky-colored bowel) and covered with sterile gauze wet with saline. Do not attempt to replace the organs. This is a surgical emergency.

Pearls

  1. Postcesarean rates of endometritis are quite high, and risk increases with length of labor prior to delivery. Up to 85% of women with prolonged labor followed by emergent cesarean section will develop endometritis without prophylactic antibiotics.

  2. Postcesarean wound dehiscence is more common with vertical incisions than with low transverse.

FIGURE 10.76

Cesarean Section Wound Dehiscence. Extrusion of intra-abdominal contents due to dehiscence of cesarean section wound on postoperative day 3. (Photo contributor: Kevin J. Knoop, MD, MS.)

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