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26 Complications ofResection ofRetroperitoneal Tumors intheFemale Pelvis
Table 26.1 Major nerves of the female pelvis and consequence of injury
Nerve Roots Sensory function Motor function Decit
Ilioinguinal L1, L2Skin of the upper anteromedial thigh
and anterior 1/3 of the labium majus
and the root of the clitoris
Iliohypogastric T12, L1Sensory bers to the external
abdominal oblique, internal
abdominal oblique, and transversus
abdominis muscles.
Skin of the suprapubic region and
the posterolateral aspect of the
gluteal region
Genitofemoral L1, L2Skin of Mons pubis and labia majora
Superior medial aspect of the thigh
Lateral femoral
cutaneous
Femoral L2,
Obturator L2,
Pudendal S2,
Superior gluteal L4,
Inferior gluteal L5,
Sciatic L4,
Posterior
femoral
cutaneous
L2, L3Skin of anterolateral aspects of thigh
Skin of anteromedial thigh, skin of
L3,
medial leg and foot
L4
Skin of the proximal part of the
L3,
medial thigh, hip joint and knee joint
L4
External genitalia and the skin
S3,
around the anus, anal canal, and
S4
perineum
L5,
S1
S1,
S2
Posterior thigh, lateral and posterior
L5,
leg, dorsum, and sole of the foot
S1,
S2,
S3
S1,
Skin of gluteal fold, superomedial
S2,
thigh, part of external genitalia,
S3
posterior thigh, and popliteal fossa
Transversus
abdominis and
internal oblique
muscles
Transversus
abdominis,
internal
abdominal
oblique muscles,
conjoint tendon,
Flexors of the
hip (pectineus,
iliacus, sartorius)
Extensors of the
knee (quadriceps
femoris)
Hip adductors
(adductor longus,
adductor brevis,
gracilis,
obturator
externus, and
ischiocondylar
part of adductor
magnus muscle)
Pelvic muscles,
the external
urethral
sphincter, and
the external anal
sphincter
Gluteus medius,
minimus, tensor
fasciae latae
Gluteus maximus
muscle
Muscles of the
posterior thigh,
ischial portion of
adductor
magnus, muscles
of the posterior,
anterior and
lateral
compartments of
the leg, foot
muscles
Loss of sensation, pain,
weakness of abdominal wall
Burning pain in the
suprapubic and inguinal
regions,
If injury above ASIS then
weakening of posterior wall
of the inguinal canal
Pain along lower abdomen
and along its course
Pain, numbness, tingling,
leg weakness, inability to
walk, loss of coordination
Numbness of mid and lower
third of medial thigh, weak
hip adduction, wasting of
the medial thigh, wide
based gait due to abnormal
hip abduction during
ambulation
Pain, numbness, sexual
dysfunction, sphincter
dysfunction (micturition,
defecation)
Gluteal medius limp or
gluteal gait (shifting of the
center of gravity to the
non-affected limb)
Pain and weakness in the
gluteal region, impaired leg
extension, lurching gait
Pain in the ipsilateral gluteal
area radiating down the
lower extremity,
Foot drop, impaired knee
exion, difculty walking,
standing, sitting
Numbness, tingling
posterior thigh, and
popliteal fossa
287
288
E. Zervos and N. A. Vohra
References
1. American Cancer Society Cancer Facts and Figures.
2023. American Cancer Society, Inc.
2. Søreide K, Sandvik OM, Søreide JA, Giljaca V,
Jureckova A, Bulusu VR. Global epidemiology of
gastrointestinal stromal tumours (GIST): A systematic review of population-based cohort studies. Cancer
Epidemiol. 2016:40:39–46. https://doi.org/10.1016/j.
canep.2015.10.031. Epub 2015 Nov 24.
3. Kwaan MR, Goldberg JE, Bleday R. Rectal carcinoid tumors: review of results after endoscopic and
surgical therapy. Arch Surg. 2008;143(5):471–5.
https://doi.org/10.1001/archsurg.143.5.471.
4. Pinchot SN, Holen K, Sippel RS, Chen H. Carcinoid
tumors. Oncologist. 2008;13(12):1255–69. https://
doi.org/10.1634/theoncologist.2008-0207. Epub 2008
Dec 17.
5. Ahmed M. Gastrointestinal neuroendocrine tumors in.
World J Gastrointest Ocol. 2020;12(8):791–807.
6. Das P, Soni P, Jones J, Habboub G, Barnholtz-Sloan
JS, Recinos PF, Kshettry VR. Descriptive epidemiology of chordomas in the United States. J Neurooncol.
2020;148(1):173–78. https://doi.org/10.1007/s11060-
020-03511-x. Epub 2020 Apr 28.
Cesarean Section
AnthonyKendle andHaywoodBrown
27
Introduction
While the exact origin of the cesarean delivery
or cesarean section is not known, descriptions of
the procedure appear in ancient mythology and
early religious practices from both western and
non- western cultures [1]. Today, it is the most
performed surgical procedure in the United
States with over 1.1 million cesarean deliveries
performed in 2023 [2]. Although the historic
doctrine of “Once a cesarean always a cesarean”
was deated in the 1990s with specic criteria
for the trial of labor (TOLAC) and vaginal birth
after cesarean (VBAC) peaking at approximately 30 percent, repeat cesarean began to rise
again in the 2000’s with VBAC rates dropping
to below 10 percent by 2010 [3]. As such, currently, the most common indications for cesarean include prior cesarean followed by labor
arrest, abnormal fetal heart tracing, and malpresentation [4]. Approximately one-third of all
A. Kendle
Obstetrics and Gynecology, Division of Maternal
Fetal Medicine, University of South Florida,
Tampa, FL, USA
e-mail: Akendle@usf.edu
H. Brown (*)
Obstetrics and Gynecology, University of South
Florida, Tampa, FL, USA
e-mail: haywoodb@usf.edu
babies are born via cesarean delivery in the
United States [5], however, cesarean rates differ
greatly across geographic regions and patient
demographics. Hospital-level cesarean delivery
rates range from 7.1% to 69.9% owing to lack of
standardization [6]. Furthermore, racial disparities exist in cesarean delivery rates such that
Black birth people are 20–30% more likely to be
delivered by cesarean compared to White counterparts [7].
Compared to vaginal delivery, cesarean deliv-
ery is consistently associated with higher rates of
maternal morbidity and mortality [8–11]. The
cesarean epidemic has ushered a generation of
reproductive-aged patients undergoing an
increasing number of repeat cesarean deliveries
resulting in a higher rate of perinatal complications. Injury to maternal bladder and bowel occur
in 0.13% and 0.11% of primary cesarean deliveries, respectively, and increases signicantly for
patients with three or more prior cesarean deliveries [12]. The increased incidence of placenta
accreta spectrum disorder with higher-order
cesarean deliveries is a substantial source of morbidity and mortality. The approach and management of this condition are described elsewhere.
This chapter reviews major complications related
to cesarean delivery including postpartum hemorrhage, unintended hysterotomy extension, uterine inversion, bladder injury, and post-cesarean
infection.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_27
291
292
A. Kendle and H. Brown
Postpartum Hemorrhage
Background
The contemporary denition of postpartum hemorrhage is blood loss exceeding 1000 mL after
vaginal or cesarean delivery or any blood loss
that results in hemodynamic instability [13]. At
term, blood ow to the uterus approaches 600mL
per minute [14]. This normal physiologic adaptation also explains why hemorrhage is a leading
cause of maternal mortality worldwide. In the
United States, postpartum hemorrhage accounts
for 11% of maternal deaths [15].
Prevention
The cesarean surgical technique is highly variable. Adherence to a standardized cesarean delivery approach may also reduce blood loss.
Specically, the Joel-Cohen Method, which
involves blunt subcutaneous dissection, fascial
extension, and peritoneal entry, has demonstrated
a reduction in operative blood loss [16]. Lowtransverse hysterotomy is preferred to a classical
(vertical) incision whenever possible to reduce
blood loss. Active management of the third stage
of labor (administering a uterine-contracting
drug within one minute from the time of delivery
until the time of placental delivery) is widely recommended and associated with signicantly less
blood loss after delivery [17, 18]. Umbilical cord
traction and uterine massage are often employed,
however, there is less data to support their efcacy. At the time of cesarean, the uterine cavity
should be inspected and cleared of any retained
placental tissue or membranes.
Recognition
Many cases of postpartum hemorrhage cannot be
prevented, however, there are several risk factors
that surgeons should be aware of to anticipate the
need for additional management and possible
transfusion. Prolonged labor induction, administration of magnesium sulfate or general anesthe-
sia, uterine broids, and chorioamnionitis impair
proper myometrial contraction after delivery.
Similarly, uterine overdistension from macrosomia, multifetal gestation, and polyhydramnios
increased the risk of uterine atony and resultant
hemorrhage. Other maternal comorbidities such
as preeclampsia, coagulopathy, and placenta
accreta spectrum disorder should be approached
with increased caution [19].
Patients with risk factors for postpartum hem-
orrhage should have vascular access with two
large bore IVs as well as type and cross-matched
blood readily available. Risk assessment tools
have been developed, but low specicity limits
their clinical utility [20]. Furthermore, many
severe hemorrhages occur in patients without risk
factors, thus surgeons must be facile with the
management strategies outlined in this section.
Management of postpartum hemorrhage begins
with anticipation and prevention and the use of
effective uterotonics in the third stage of labor.
Delayed recognition of hemorrhage is the most
common reason for adverse outcomes. Assessing
the etiology of excessive bleeding is paramount
to successful management. Although 70–80% of
postpartum hemorrhage results from uterine
atony, blood loss from surgical dissection, vessel
injury (uterine artery, inferior epigastric artery,
etc.), or adherent placenta must be evaluated
since management is distinct [13].
Management
Uterotonics are the rst-line treatment for hemorrhage secondary to uterine atony. When recognized, infusion of oxytocin 10–40 units per
500–1000 mL or intramuscular injection of
10 units is the rst step of management.
Methylergonovine is an ergot alkaloid that acts
directly on uterine smooth muscle. It is administered as an intramuscular injection of 0.2 mg
every 2–4 hours. Methylergonovine should not
be used in patients with hypertension, cardiovascular disease, or in combination with protease
inhibitors. Prostaglandin F2α binds to uterine
prostaglandin receptors causing smooth muscle
contraction and vasoconstriction. It is adminis-
27 Cesarean Section
293
tered as an intramuscular injection of 0.25 mg
every 15minutes up to eight doses. It should be
avoided in people with asthma due to bronchospasm. Misoprostol (Cytotec) 1000 microgram
tablets given orally or rectally have a similar,
albeit delayed, mechanism of action [21].
Intravenous tranexamic acid inhibits brinolysis
and is an adjunctive treatment for postpartum
hemorrhage. It has been shown to reduce
hemorrhage- related mortality by 20% when
given within 3hours of birth [22].
Mechanical tamponade is the next step in
management for refractory hemorrhage secondary to atony. Commercially available balloon
tamponade kits can be inserted either through the
cervix or cesarean incision, inated with sterile
saline, and left in situ and deated over time to
provide tamponade in addition to blood drainage
[13]. Approximately one-quarter of patients who
receive intrauterine balloon tamponade will
require additional intervention or surgery [23].
Balloon tamponade is a temporizing intervention
in controlling PPH which allows uterotonic medication and hemodynamic stabilization to occur
before coagulopathy further contributes to morbidity and mortality. While tamponade balloons
can be placed at the time of cesarean, other intraoperative techniques are effective at reducing
blood loss. Uterine compression sutures are commonly employed to address uterine atony and are
effective in controlling hemorrhage in 60–75% of
cases [23, 24]. The B-Lynch technique [25] is
often described. Here, a large, rapidly absorbable
(e.g., 1-0 chromic) suture is passed from the cervix/lower uterine segment (to one side of the
midline) and over the ipsilateral cornu. The
suture is then passed through the posterior lower
uterine segment to the contralateral side, draped
over the contralateral cornu, and anchored in the
anterior lower uterine segment. The suture is then
tied in such a fashion that the “suspenders”
formed by the suture compress the uterus externally. It is important to use a rapidly absorbable
suture to avoid uterine necrosis and bowel herniation as the gravid uterus involutes after delivery.
Vascular ligation techniques can be used to
reduce blood ow to the atonic uterus or to directly
address injured vasculature from unintended hys-
terotomy extension. Bilateral uterine artery ligation—known as O’Leary sutures—is a second-line
approach to manage hemorrhage and can be rapidly accomplished at the time of cesarean [26]
(Fig. 27.1). The uterine artery is rst identied
based on visualization or palpation of pulsation.
An absorbable suture is then passed from the anterior lower uterine segment at a site approximately
2–3 cm medial to the uterine artery through the
posterior lower uterine segment. The suture is then
passed anteriorly through an avascular space identied in the broad ligament lateral to the uterine
artery. The suture is then tied to effectively compress the ascending uterine artery against the lateral uterus. This technique is repeated on the
contralateral uterine artery. Ligation of the internal
iliac/hypogastric artery ligation has been described
historically. In contemporary practice, this technique is rarely employed owing to a 40% failure
rate ultimately requiring hysterectomy [27].
Furthermore, many obstetricians avoid the extensive retroperitoneal dissection required to perform
this technique, especially in the setting of new,
alternative interventional radiological methods to
control hemorrhage.
Uterine artery embolization (UAE) is an
increasingly utilized intervention that avoids the
infertility and morbidity associated with cesarean
hysterectomy [28]. While hysterectomy is the
preferred option for refractory bleeding during
cesarean or when hemodynamic instability is
compromised, UAE is particularly useful in stable patients with concern for persistent intraperitoneal bleeding after surgery or in patients who
experienced delayed postpartum hemorrhage.
Fluoroscopic embolization of uterine and extrauterine vessels with Gelfoam or microparticles
has demonstrated a median success rate of 89%
from meta-analysis [29], although some large
single-center studies report rates of bleeding control that approach 100% [30]. Complications are
rare but include rebleeding (5–10%), uterine
infarction, and infection [28]. Overall, data
regarding future fertility is favorable [31].
Cesarean hysterectomy is reserved for postpartum hemorrhage refractory to techniques
described above. Further discussion of this procedure is described in Chap. 30.
294
Uterine Artery Ligation
ry
Ut
ligament
A. Kendle and H. Brown
Uterus
Cervix
Vagina
erine artery
Myometrium
Ligature
Broad
Fig. 27.1 Bilateral uterine artery ligation at time of
cesarean delivery. This gure depicts a technique for ligation of the uterine artery to control bleeding at times. An
absorbable suture is passed through the myometrium at a
site 2–3 cm medial to the uterine artery. The needle is
passed from anterior to posterior. The operator’s other
Ovarian suspenso
ligament
Ovarian artery
Ligated ascending
uterine artery for
hemorrhage control
Ureter
Internal iliac artery
hand is used to retract the broad ligament and identify an
avascular space lateral to the uterine artery. The needle is
then passed through this avascular space from posterior to
anterior. The suture is then tied down to compress the
ascending uterine artery against the lateral uterus. This
process can be repeated on the contralateral uterine artery
repair, and have lasting implications for subse-
Unintended Hysterotomy Extension
quent pregnancy (Fig.27.2).
Background
Contemporary cesarean delivery of a term infant
employs a low-transverse hysterotomy whenever
possible due to the association with lower blood
loss and reduced risk of uterine rupture in
subsequent pregnancy compared to classical (or
vertical) hysterotomy. Unintended extension of
the surgically created hysterotomy occurs in
4–15% of cesarean deliveries [32], and is particularly common following cesarean delivery after a
prolonged (>4hour) second stage [33]. Extension
into surrounding tissue such as the contractile
myometrium, broad ligament, cervix, and vagina
can result in damage to vascular and urinary tract
structures, pose unique challenges for surgical
Prevention
Hysterotomy extension may be unavoidable in
cases of emergent cesarean delivery when fetal
wellbeing supersedes regard for maternal tissue or
with complicated extraction of a deeply impacted
fetal vertex. Appropriate selection of the location
for the low-transverse hysterotomy is paramount. In
the labored uterus, the lower uterine segment anatomy is altered and the hysterotomy should be made
1–2cm superiorly to avoid inadvertent incision into
the cervix or vagina. Additionally, it is recommended that expansion of the initial hysterotomy to
size to facilitate the fetus should be performed
bluntly by pulling in the cephalon-caudad rather
Extension to contractile
Extension to
Hy
27 Cesarean Section
295
sterotomy
Cervix
Vagina
myometrium
Extension to deep pelvis with
vaginal or cervical involvement
broad ligament
Uterus
Ureter
Fig. 27.2 Potential paths of unintended hysterotomy
extension at the time of cesarean delivery. This gure
depicts the uterus with unrepaired hysterotomy immediately after delivery of the infant and placenta. Unintended
extensions of the hysterotomy relative to surrounding
anatomy are shown including superior extension into the
than laterally [16]. During delivery, the operator
should minimize movement at the wrist when rotating the occiput to anterior and lifting the fetal
occiput into and through the hysterotomy and
instead leverage from the shoulder along the axis of
the maternal midline parallel to the operating table.
A second operator may assist with elevation of a
deeply impacted fetal head from a vaginal approach
so that the operator can rotate the occiput and
deliver the fetal vertex without lateral motion of the
hand and risk of extensions and vascular injury.
Vacuum can assist in the delivery of the fetal occiput
at cesarean and has been shown to reduce uterine
extensions and associated complications [34].
contractile myometrium, extension into the broad ligament with subsequent injury to the ascending uterine
artery, and extension into the deep pelvis that may involve
the cervix and/or vaginal fornixes. In the latter extension,
attention to the relationship of the potential extension to
the uterine artery and ureter is necessary
Recognition
The inability to visualize the apices of the hysterotomy suggests an unintended extension.
Extensions are often accompanied by persistent
bleeding, which further complicates visualization. The appearance of a hematoma at the hysterotomy apex or within the broad ligament
may indicate extension. Development of hemoperitoneum, maternal hemodynamic instability,
and/or persistent vaginal bleeding in the
absence of uterine atony postpartum may indicate an incompletely repaired or unrecognized
extension.
296
A. Kendle and H. Brown
Management
The surgical site should be carefully examined to
locate the apices of hysterotomy. Palpation can
be helpful in identifying an apex that is poorly
visualized due to pelvic anatomy or surgical
bleeding to understand the extent of repair
required. Allis or Pennington clamps can be used
to grasp the apex and move it into the surgical
eld. The apex must be clearly identied and
secured with delayed absorbable suture and
inspected for hemostasis which, if not identied,
can lead to intrabdominal hemorrhage, morbidity, and potential mortality in the immediate
hours after delivery. The operator must be mindful when placing these stitches to avoid injury to
the uterine artery and ureter, especially with
extensions into the deep pelvis. In these circumstances, sutures should be thrown along a craniocaudal axis when possible, avoiding lateral
deviation. The uterine artery and broad ligament
can be gently retracted posterolaterally with the
operator’s other hand to facilitate good purchase
of uterine tissue when repairing extensions.
A transvaginal inspection of the cervix and
fornixes may be necessary to assess for and close
extensions that could not be addressed
abdominally.
mate the transverse muscle layer to muscle. Data
also suggest that a second imbricating layer adds
strength to the healing incision. In a study by
Bujold et al of 1768 women with one prior lowtransverse cesarean incision ndings associated
with overt uterine rupture were single layer closure
(OR 7.5, 95% CI—3.2–17.6) and inter- delivery
interval< 18 months (OR 2.8, 95% CI—1.2–6.6)
[36]. Patients with more than two prior cesareans,
prior classical hysterotomy (or other hysterotomy
extending into the contractile myometrium), or
those with prior myomectomy or uterine surgery
that resulted in a full-thickness myometrial disruption should not undergo a trial of labor due to the
increased risk of uterine rupture.
Recognition
The harbingers of uterine rupture can be subtle or
even absent. Classically described signs and
symptoms of intrapartum rupture include abnormal fetal heart rate (variable decelerations or bradycardia), sudden loss of fetal station, vaginal
bleeding, and acute, severe uterine pain [35].
Management
Uterine Scar Dehiscence
Background
Separation of a prior hysterotomy scar during
labor is a signicant source of maternal and neonatal morbidity. Uterine scar dehiscence occurs
during the trial of labor in approximately
0.5–0.9% of people after one prior cesarean and
up to 3.7% after more than one cesarean [35].
Prevention
A major risk factor for uterine scar dehiscence and
uterine rupture is the closure of the initial lowtransverse or classical hysterotomy incision. In the
initial closure care should be taken to reapproxi-
Repair of silent dehiscence or overt uterine rupture depends on the damage to tissue in the old
scar. Attempts should be made to trim the scar
until a layer of muscle can be identied to be
reapproximated. This may prove to be difcult
for the thin inferior transverse scar with an adherent bladder. Hysterectomy should be considered
in cases where tissue damage from the rupture is
extensive or bleeding is unable to be controlled.
Uterine Inversion
Background
Inversion of the uterine corpus is a rare obstetrical emergency that complicates 1in 3448 deliveries [37]. Although most cases of uterine inversion
are idiopathic, there is an association with certain
27 Cesarean Section
297
conditions including fundal placenta, short
umbilical cord, placenta accreta, uterine tumors,
and uterine atony. Because inversion can provoke
massive hemorrhage, it is associated with substantial maternal morbidity. Classical uterine
inversion occurs at the time of vaginal delivery
during the third stage of labor (after delivery of
the infant until the time of placental delivery) by
which the uterine fundus herniates through the
cervical os. This complication can also arise at
the time of cesarean section during or after delivery of the placenta by which the uterine fundus
may invert through the open hysterotomy.
Prevention
There is no precipitating factor identied in many
cases of uterine inversion. Prevention is dependent upon proper management of the third stage
of labor. Avoiding excess traction on the umbilical cord during placental delivery is the primary
way to reduce the incidence of inversion.
Huntington procedure [38], the operator places
an Allis or Babcock clamp on each round ligament as it enters the defect created by the inversion. Gentle upward traction is placed on the
clamps. Additional clamps are placed as the fundus everts until the inversion is corrected. A second operator may assist with manual reduction
from a vaginal approach. Alternatively, during
the Haultain procedure [39], a 3–4cm incision is
made in the myometrium on the posterior aspect
of the constriction ring above the inverted fundus. The fundus can then be reduced either
through the newly created posterior uterine defect
or vaginally.
After successful reduction of uterine inversion, uterotonic medication should be administered and the patient should be observed until the
operator conrms adequate uterine tone.
Resuscitation with IV uids and blood products
is continued as needed, and the patient is observed
for signs of re-inversion. Strict urinary output is
measured to assist with volume resuscitation and
assess for ureteral obstruction that may occur
with re-inversion.
Recognition
Overt uterine inversion is recognized by a visible
or palpable mass at the introitus before or after
placental separation. The sudden onset of massive bleeding with rapid progression to shock are
ominous signs of a uterine inversion.
Management
The placenta should be left attached to the inverted
uterine wall if possible. Gradual pressure is applied
to the inverted fundus either with the operator’s st
or palm and ngertips to restore usual anatomy
through the cervix or hysterotomy. Uterine relaxants such as nitroglycerine, halogenated anesthetic
agents, or terbutaline can be administered to facilitate manual replacement [19].
Proceeding to surgical management after
unsuccessful attempts to correct inversion must
occur quickly via laparotomy, especially if the
patient is hemodynamically unstable. For the
Bladder andBowel Injury
Background
Bladder injury can occur at the time of primary or
repeat cesarean section. In a prospective cohort
study of 30,000 cesarean sections, cystotomy
occurred at 0.09% at the rst repeat compared to
0.13% with initial cesarean section. Bowel injury
occurred at 0.06% for rst repeat compared to
0.11% with initial cesarean section [12].
Intraoperative recognition and repair of injury
will generally prevent major morbidity.
Prevention
Blunt entry into the peritoneal cavity can reduce
the risk of injury to adherent bowel from prior
cesarean deliveries, but the operator should enter
through a clear peritoneal window when possible
[40]. Identication of the bladder is imperative
298
A. Kendle and H. Brown
prior to performing hysterotomy, especially in
repeat cesarean section where the bladder dome is
often pulled up and adherent to the old hysterotomy scar. Fetal distress may preclude careful tissue dissection, and damage to these structures may
occur in the course of preventing fetal morbidity.
Recognition
Urine or bowel contents (other than meconium)
may be present in the surgical eld. Although
postoperative oliguria, urinary retention, and
ileus may be common after routine cesarean section, a bladder or bowel injury should remain on
the differential, especially when the cesarean section was performed emergently or complicated
by anterior scarring or bowel adhesions.
Management
Techniques for repairing bowel and bladder
injury are outlined elsewhere in this book.
In general, a cystotomy is repaired in two layers by delayed absorbable suture, followed by
1–2weeks of bladder drainage with a Foley catheter. A small enterotomy requires meticulous one
or two-layer closure with care to avoid constriction of the lumen of the bowel.
Post-Cesarean Infection
Background
Surgical site infection (SSI) occurs in 1.4–3.8%
of cesarean deliveries [41]. The nature of pregnancy and cesarean delivery impose inherent risk
for infection, including immunosuppression of
pregnancy, pharmacodynamic changes, the need
for inadvertent entry into the genital tract (especially in the patient with ruptured membranes),
and the urgent/emergent nature of unscheduled
delivery that may preclude proper sterile technique. Most infections after cesarean delivery are
polymicrobial, arising from skin or genital tract
ora. Endometritis—inammation and infection
of the decidua—can develop after vaginal or
cesarean delivery and is distinguished by exquisite uterine tenderness.
Prevention
Risk factors for post-cesarean wound infection
include obesity, chorioamnionitis, blood transfusion, and cigarette use [42]. The risk for infection is highest in those who undergo an
unscheduled cesarean delivery in the second
stage of labor. Evidence-based bundles are effective at reducing surgical site infection by 66%
based on a meta- analysis [43]. Components of
best practice prevention include antibiotic prophylaxis, use of hair clippers (instead of razors),
chlorhexidine abdominal preparation, spontaneous placental removal, and staff education.
Appropriate antibiotic prophylaxis is paramount.
For patients undergoing scheduled cesarean
delivery, cefazolin 1–2g IV prior to incision provides appropriate coverage. Some evidence suggests that a 3g dose is appropriate for patients
whose weight exceeds 120kg [42]. For patients
with a known diagnosis of chorioamnionitis
prior to cesarean delivery, a regimen of ampicillin, clindamycin, and an aminoglycoside provides broader coverage, and should be continued
for 24 hours after delivery. The addition of
azithromycin 500 mg IV in patients with
unscheduled cesareans who are in labor or have
ruptured membranes has been shown to reduce
the risk of surgical site infection by 50% [44].
Additional evidence-based surgical techniques
to reduce infection include non- closure of the
peritoneum and re-approximation of the subcutaneous fat when the subcutaneous thickness is
≥2cm [40]. Careful attention to closure of the
abdominal incision, judicious cauterization of
subcutaneous bleeding, and closure of the subcutaneous tissue in women with an obese BMI
can avert serious wound morbidities including
hematomas and infections. Care of the wound in
the immediate postpartum period and following
within the rst weeks facilitates early detection
of a wound complication and may avert
morbidities.