DOI: 10.1111/tog.

12280 2016;18:265–72
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Complications of caesarean section

a, b
Alexander Field BSc MBBS PGCertMedEd MRCOG, * Rahim Haloob FRCOG
a
Specialist Registrar in Obstetrics and Gynaecology, Department of Women and Children’s Health, Colchester Hospital University Foundation
Trust, Colchester, Essex CO4 5JL, UK
b
Consultant Obstetrician and Gynaecologist, Department of Women and Children’s Health, Basildon and Thurrock University Hospital Trust,
Basildon, Essex SS16 5NL, UK
*Correspondence: Alexander Field. Email: alexander.field@doctors.org.uk

Accepted on 11 January 2016

Key content Learning objectives

 The incidence and presentation of complications of  To be aware of the most common and serious complications of
caesarean section. caesarean section.
 The surgical management of intrapartum and  To be able to describe recognition and initial surgical management
postpartum haemorrhage. of suspected bladder, ureteric and bowel injuries.
 Risk factors for, and prevention and treatment of  To be familiar with delayed presentations of visceral injuries and
postpartum sepsis. have a systematic approach to investigation of suspected injury.
 Presentation, investigation and repair of bladder injuries  To understand the impact of caesarean section complications in
when recognised intraoperatively and following resource-poor countries.
delayed presentation.
Ethical issues
 Risk factors for, and recognition and management of suspected
 Appropriate, accurate preoperative counselling regarding risks
ureteric injury intraoperatively and postoperatively.
and consent.
 Bowel complications including intraoperative bowel
 Awareness of personal competency in managing
injury and management, postoperative ileus and
specific complications.
Ogilvie syndrome.
 Particular risks and complications associated with caesarean Keywords: caesarean section / complications / haemorrhage / ileus /
section at full dilatation. Ogilvie syndrome / sepsis / visceral injury
 Caesarean section in the developing world.
Linked resource: Single best answer questions are available for this
article at https://stratog.rcog.org.uk/tutorial/tog-online-sba-resource

Please cite this paper as: Field A, Haloob R. Complications of caesarean section. The Obstetrician & Gynaecologist 2016;18:265–72. DOI: 10.1111/tog.12280

be encountered and the obstetrician must be familiar with

Introduction
and able to rectify these.
Caesarean section is one of the commonest operations
performed in the UK and its incidence is increasing.
Haemorrhage
According to the Hospital Episode Statistics data for
2013–2014 the caesarean section rate for England was Caesarean section is a risk factor for postpartum
26.2% (or 166 081 operations), an increase on the previous haemorrhage, although a wide range of definitions and
year.1 In addition to the increasing rates in developed risks are quoted in the literature. The National Institute
countries, rates are increasing in some developing for Health and Care Excellence (NICE) guideline on
countries.2 The majority of these proceed smoothly and caesarean section gives a rate of 1.1% for postpartum
safely; however, caesarean section is a major, open haemorrhage following planned caesarean section versus
abdominal procedure, often performed in an emergency 6.0% for planned vaginal birth (although in the study
setting. The incidence of re-laparotomy after caesarean that NICE obtained these figures from, 35% of women
section is 0.12–1.04%,3,4 the most common indications in this group actually had an unplanned
being intra-abdominal bleeding, intra-abdominal abscess or caesarean section).5
bladder and bowel complications.4 As such, there are a Magann et al.6 looked at over 4000 caesarean deliveries in
number of immediate and delayed complications that may Australia. The incidence of postpartum haemorrhage in

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 Complications of caesarean section

emergency caesarean was 6.75% and 4.74% for elective Should initial surgical and medical attempts to arrest
caesarean. Risk factors included placenta praevia, general bleeding fail, there are several second-line options. Some
anaesthesia, obesity, labour dystocia, antepartum/ units have access to interventional radiology services that are
intrapartum haemorrhage, birthweight of greater than 4 kg able to find and embolise specific bleeding points and,
and the presence of uterine fibroids.6 ideally, patients with morbidly adherent placenta should
Haemorrhage at caesarean occurs for a number of reasons, deliver in a unit with access to interventional radiology.
including uterine atony, tissue trauma (for example, uterine Internal iliac artery ligation may be attempted, although this
angle extensions, cervico-vaginal trauma, bladder injury or is a procedure many obstetricians are not familiar with.
bleeding from adhesions), coagulation defects and problems Ultimately, hysterectomy may be necessary; although when
with the placenta. The treatment of haemorrhage at caesarean done at caesarean it is associated with high rates of
must be directed at the cause. Uterine atony is treated with complications, including bladder trauma, ureteric injury
uterotonic medications, such as syntocinon, ergometrine, and re-laparotomy as discussed by Sackinki et al.9 in their
carboprost and misoprostol. If these fail, surgical methods case series.
such as intrauterine tamponade balloon and/or compression
sutures (for example, B Lynch) should be employed.7
Postoperative sepsis
Bleeding due to trauma can be minimised by using a
careful surgical technique. The uterus should be checked for Caesarean section is the most important risk factor for
dextro-rotation and this should be corrected prior to uterine postpartum sepsis, which may arise from a number of
incision. Similarly, care should be taken to avoid opening the sources. Wound infection and endometritis are the
uterus too inferiorly, especially in the advanced stages of commonest sites of postoperative infection, although the
labour when the lower segment may be difficult to delineate. urinary tract, respiratory tract and nervous system must also
The fetal head should be gently disimpacted and delivered be considered. The risk of sepsis is, unsurprisingly, higher for
through the uterine incision. These measures reduce the risk emergency compared with elective caesarean section. A 2014
of uterine angle extensions, broad ligament trauma and Cochrane review suggested a rate of wound infection of 97
urinary tract injury.7 per 1000 and 68 per 1000 for emergency and elective
Bleeding as a result of trauma should be arrested by caesarean section, respectively; for endometritis the rates
prompt surgical repair. Uterine angle extensions should be were 184 per 1000 versus 39 per 1000.10 The review also
repaired, ensuring that the angles are adequately secured. showed that prophylactic antibiotics led to a relative risk of
Extensions downwards and laterally may be close to the endometritis of 0.38 (95% confidence interval [CI]
ureters. Tears in the lower segment extending downwards 0.34–0.42),10 hence prophylactic antibiotics prior to skin
towards the bladder should be closed from apex to incision are one of the most important ways of reducing
incision.7 The bladder may need to be mobilised further postoperative sepsis.10 Meticulous attention to haemostasis
to prevent inclusion within sutures but should also be and appropriate consideration and placement of drains may
checked to ensure it is not damaged. Extensions upwards also lead to a reduction in postoperative collections.11
into the upper segment should be closed in a similar Wloch et al.12 examined other risk factors and found that
fashion to a classical caesarean section, carefully obesity and maternal age under 20 years were independent
documented and accompanied by advice for future risk factors for surgical site infection, and that rates of
deliveries.7 There may be a complete hole in the broad infection were lowest when the caesarean section was
ligament and possible extension into the posterior aspect of performed by a consultant.12 The overall rate of surgical site
the uterus; this hole should be closed to prevent bowel infection was 9.6% and the commonest organisms isolated
herniation. Within the broad ligament lie both branches of were Staphylococcus aureus, anaerobes and enterobacteriaceae
the uterine arteries as well as the uterine arteries themselves, such as Escherichia coli (E. coli) and enterococcus.12
which can be torn. Haemostatic sutures can be placed to A Cochrane review from 2014 found that routine
secure bleeding and, if needed, the uterine vessels can be preoperative vaginal cleansing with povidone-iodine
ligated. This is done by taking a suture through the lateral solution reduced the risk of postpartum endometritis
aspect of the uterus at the level of the incision and back (relative risk 0.45, 95% CI 0.25–0.81) but showed no
through an avascular window within the broad ligament, or statistically significant effect on wound infection or pyrexia.13
the broad ligament can be opened.7 There is little definitive evidence regarding wound closure
Bleeding from the placental bed, such as with placenta and the risk of sepsis. A 2012 Cochrane review examined
praevia or placenta accreta, can be managed with figure of wound closure techniques at caesarean section.14 The two
eight haemostatic sutures or intrauterine balloon most commonly compared methods were staples and
tamponade.7 Intravenous tranexamic acid may be a useful subcuticular absorbable sutures. There was no statistically
adjunct in all cases of haemorrhage.8 significant difference in terms of pain, cosmetic appearance

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 Field and Haloob

or infection rates. Staples were associated with a slightly Bladder injury

higher risk of skin separation after removal but the definition
of skin separation was heterogeneous across the studies, as Bladder injury at caesarean section is uncommon. The
was the time of staple removal (in some studies staples were Royal College of Obstetricians and Gynaecologists
removed on day 3 postoperatively).14 (RCOG) suggests there is a rate of 1 in 1000, whereas a
There is also little evidence regarding the treatment of large case–control study from Turkey looking at over
postoperative sepsis. The initial priority is haemodynamic 56 000 caesarean sections reported an incidence of 0.13%.18
stabilisation and administration of broad spectrum Risk factors from this study included age, parity, previous
antibiotics active against likely organisms. Appropriate caesarean section, previous pelvic surgery, the presence of
cultures should be taken, ideally prior to administering but adhesions, station of presenting part lower than or equal to
not delaying the antibiotics; these may be wound swabs, +1 cm, birthweight more than 4 kg, and caesarean section in
blood cultures, urine cultures or vaginal swabs. Wound pain, labour, although these are not necessarily independently
erythema and offensive discharge are suggestive of superficial associated. Bladder injury has been reported more frequently
infection whereas endometritis is characterised by heavy in those attempting vaginal birth after caesarean compared
lochia, which may be offensive and associated with with those undergoing elective repeat caesarean section.19 In
abdominal pain. Imaging is often requested but may be primary caesarean section, most bladder injuries occurred
difficult to interpret. A study from 2004 reviewed 100 women during peritoneal entry whereas in repeat caesarean section,
who underwent caesarean section followed by routine most occurred during dissection of the bladder from the
ultrasound scan postoperatively on day 4. Interestingly, lower uterine segment (bladder flap creation).18
48% had ultrasound evidence of a fluid collection either There is an argument for avoiding routine creation of a
within the abdominal wall or the abdominal cavity and the bladder flap as several case series have reported this as a time
study concluded that the presence of this was not associated when bladder trauma may occur. There is also evidence that
with postoperative morbidity.15 omitting this step reduces bleeding and operative times;
A small proportion will not respond to conservative however, there is no evidence that this reduces the rates of
management. In these women, it seems sensible to perform bladder injury, largely because of the difficulty in performing
imaging before proceeding to surgical intervention. There is an adequately powered study.20
little published literature to guide management. Some will Bladder injury has an excellent prognosis if recognised
need formal surgical exploration of the wound, and, if intraoperatively and appropriately repaired. There should be a
required, the abdominal cavity. Aspiration of any collection, high suspicion of injury if peritoneal entry was difficult or if
pelvic washout and drain insertion may suffice. Deep seated there are significant pelvic adhesions. Injury may be obvious,
infection may need debridement and re-closure of the uterine with a visible laceration to the bladder, extravasation of urine,
incision. Other women may be managed with radiological- visible catheter balloon, frank haematuria or significant
guided drainage of the collection. It may be wise, especially if bleeding not arising from the uterine incision.18 Retrograde
there are risk factors for poor wound healing, to seek an instillation of methylene blue may be useful if injury is
opinion from the tissue viability team or a vascular surgeon suspected but not obvious, and to check the integrity of repair
concerning re-closure of the abdominal wound. It may be once complete. Most injuries involve the dome of the bladder
necessary to debride the wound back to vitalised tissue and and may be closed with an absorbable suture by an experienced
close with interrupted sutures or staples to allow drainage. obstetrician using a 2-layer technique. However, extensive
There is little specific evidence concerning negative pressure bladder injury, especially if there is a suspicion of ureteric or
wound therapy in this situation but it may have a role, ureteric orifice involvement, should be repaired by a
especially in women with risk factors such as high body mass urologist.18 Postprocedure management includes indwelling
index, diabetes or smoking.16 catheter drainage and prophylactic antibiotics for 10–14 days.
Puerperal necrotising fasciitis is uncommon and may After this, a cystogram may be performed to check bladder
follow vaginal delivery or caesarean section. The integrity and the catheter removed.
physiological immunosuppression of pregnancy may be If bladder injury is not detected intraoperatively, it may
augmented by significant anaemia, malnutrition or present with urinary ascites, urine draining from an
diabetes.17 The clinical presentation is with pain out of abdominal drain, oliguria from a catheter with otherwise
proportion to the clinical findings and accompanied by normal observations, deranged renal function secondary to
extremely rapid disease progression. Infection may be peritoneal reabsorption of urea and electrolytes,21
polymicrobial.17 Initial treatment of infection is broad incontinence due to vesico-uterine fistula or intra-
spectrum antibiotics, fluid resuscitation and senior abdominal haemorrhage.18 In this case, urological opinion
multidisciplinary review because early, extensive surgical is vital and re-operation the likely outcome. Imaging is
debridement is required. usually by computed tomography (CT) cystogram after

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 Complications of caesarean section

retrograde bladder filling with contrast via an indwelling can assess patency and has the advantage over intravenous
catheter. If there is a suspicion of upper renal tract injury as urogram in that it images other pelvic organs in the case of
well or diagnostic uncertainty, CT with intravenous contrast diagnostic uncertainty. Delayed sequences may be needed to
may be required.22 see if contrast is collecting outside the ureter. If diagnostic
uncertainty remains then cystoscopy with formal retrograde
ureterogram can be done, but this is more invasive than
Ureteric injury
either an intravenous urogram or CT.26
Ureteric injury at caesarean section is substantially less Management depends on the injury and location: partial
common than bladder injury but much less likely to transection may be treated by ureteric stent placement,
be recognised intraoperatively.23 A large audit of complete transection may be managed by
11 284 caesareans found 16 cases of bladder injury and 4 cases ureteroneocystostomy (re-implantation of the proximal
of ureteric injury, giving a rate of 0.27 per 1000 caesarean ureter into the bladder) or ureteroureterostomy (re-
sections. Rajasekar and Hall23 reported that all bladder injuries anastomosis of the cut ureter),27 and occlusion with a
were noted intraoperatively, whereas only 1 of the 4 ureteric suture may be treated by removal of the suture and/or
injuries were detected as it co-existed with a bladder injury.23 stenting of the ureter, if needed. A case series from Turkey
Other sources state that ureteric injuries are missed looked at ureteric injuries diagnosed late after caesarean
intraoperatively in approximately 70% of cases.24 section and managed percutaneously.28 The average time to
The ureters may be damaged in several ways but the recognition was 21 days but the maximum delay in diagnosis
commonest during caesarean are transection and ligation (or was 8 months. They performed anterograde pyelography to
kinking) by a suture. Transection can occur when there is delineate the lesion, followed by percutaneous nephrostomy.
extension of the uterine incision into the broad ligament. In In cases of obstruction, they performed weekly pyelograms
this situation, they are also at risk of inclusion within a suture through the nephrostomy and awaited dissolution of the
during attempts at haemostasis because of the close sutures. They also reported that five cases of partial
proximity of the ureters to the uterine arteries.25 The transection, including one of ureterovaginal fistula, were
ureters are also at risk where they join the bladder and, in treated entirely percutaneously. Overall 75% of ureteric
this case, may be damaged as part of a concomitant bladder injuries were managed percutaneously.28
injury or attempts to repair a bladder injury.23,26
Whereas bladder injury is usually obvious during caesarean Bowel injury
section, ureteric injury is not and there must be a high index
of suspicion to find it. If there is concern, a urologist should Immediate bowel injury is a rare complication and the RCOG
be contacted. Intravenous injection of dye and transurethral consent advice does not list bowel injury as a serious risk, but
cystoscopy can be used to demonstrate ureteric patency.26 rather refers to the possibility of bowel repair as an additional
When not recognised intraoperatively, ureteric injury may procedure.29 Compared with bladder injury, there is much
present in a number of ways depending on the injury, less published literature on intraoperative bowel injury. The
location and length of time postoperatively. Bilateral distended gravid uterus displaces the bowel from the
complete occlusion or transection of the ureters will result operative field at caesarean section; however, the bowel can
in postoperative anuria. Other signs and symptoms include still be damaged in several ways. Loops of bowel may be
fever, haematuria, flank pain, abdominal distension, sepsis/ adherent to the anterior abdominal wall, particularly if there
peritonitis/ileus, or retroperitoneal urinoma formation. has been a history of surgery via midline incision, and may be
There may be urinary leakage from the vagina suggesting damaged during peritoneal entry or if extensive division of
fistula formation or from the abdominal wound or drain adhesions are required prior to delivery. After delivery, the
suggesting intra-abdominal urine collection.26 Renal function bowel can be damaged during closure. While the uterus is
testing may suggest renal failure due to obstructive being closed, particularly if there are angle extensions, it is
nephropathy in the case of occlusion or metabolite possible to include loops of bowel within the sutures,
reabsorption where there is transection. Conversely, it may posterior to the uterus. Exteriorisation of the uterus allows
present much later with secondary hypertension because of direct visualisation of the posterior aspect of the uterus and
obstructive nephropathy.26 should be considered if there are significant extensions.
If ureteric injury is suspected postoperatively then imaging It is essential to diagnose bowel injury intraoperatively and
should be done to confirm and identify the nature and site of ask a surgeon to attend for the repair. These injuries may
any injury. Renal ultrasound is useful for visualising the often be treated with primary closure if small, even in
kidneys and identifying hydronephrosis. It is noninvasive but unprepared bowel, but if larger or multiple they may require
cannot confirm continuity of the ureter or identify the exact resection of the damaged bowel segment. It is vitally
level and nature of obstruction. CT with intravenous contrast important to avoid damaging the bowel with diathermy as

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 Field and Haloob

thermal injury may be difficult to spot and the patient may nasogastric tube. Renal function and electrolytes should be
present 48–72 hours later with bowel perforation secondary checked and abnormalities corrected. Opiate analgesia, which
to tissue necrosis.30 can impede bowel function, should be minimised.35
There is little specific literature on management of bowel The main diagnostic challenge is excluding the unlikely
injury at caesarean. A case series of ten patients from 2011 but more serious causes of bowel obstruction; these
looked at primary repair against colostomy and concluded include immediate postoperative adhesion formation,
that primary repair should be attempted for all traumatic intra-abdominal sepsis, Ogilvie syndrome, and
colonic injuries and intraperitoneal rectal injuries. The causes unrecognised intraoperative bowel injury. For patients
of bowel trauma in this case series were predominantly failing to improve with simple conservative measures or
penetrating abdominal trauma, so caution needs to be used who appear more unwell than expected for postoperative
when considering generalisability to iatrogenic ileus, an abdominal X-ray is a useful initial investigation.
surgical injury.31 Gas throughout the abdomen, including both large and
Bowel injury not recognised intraoperatively will usually small bowel, is more suggestive of paralytic ileus, whereas
present with signs and symptoms of intra-abdominal sepsis. distended loops of small bowel with no gas in the colon is
This may be delayed for several days in the case of more suggestive of a mechanical obstruction. X-ray allows
perforation following diathermy injury. CT imaging may be the caecal diameter to be measured if Ogilvie syndrome is
undertaken and show extraluminal air and fluid, although suspected. Similarly, a CT scan of the abdomen gives the
these may also be a normal finding in the immediate same information but will also show intra-abdominal
postoperative period. Distended loops of bowel, evidence of collections and show the obstruction transition point of
inflammation/abscess formation and, particularly, the bowel more precisely.35
extravasation of oral contrast material are much more
suggestive of gastrointestinal perforation.32 Re-operating in
Ogilvie syndrome
the presence of peritonitis is much more likely to require
colostomy than if injuries are identified at the time of Ogilvie syndrome is defined as acute large bowel obstruction
primary surgery. without a mechanical cause.36 It is not specific to caesarean
section but can occur in any patient undergoing surgery and,
indeed, has been reported in nonsurgical patients with
Postoperative ileus
serious underlying medical conditions. The exact
Postoperative ileus refers to severe constipation and pathophysiology is unknown but it may be due to an
intolerance of oral intake due to non-mechanical causes imbalance in the autonomic innervation of the distal colon
after surgery. It may be a normal, physiological response to leading to atony and subsequent proximal dilatation. During
abdominal surgery, but may also occur in patients after other a caesarean section, Ogilvie syndrome may be caused by
forms of surgery. The pathogenesis of postoperative ileus is damage to the sacral parasympathetic nerve supply, which
not fully understood and causation is likely to be runs close to the cervix, vagina and broad ligament.36 The
multifactorial.33 The incidence of ileus after gynaecological classic presentation is progressive abdominal distension,
procedures has been estimated to be 10–15% although there which may initially be painless and associated with varying
is a paucity of specific data for caesarean section. A 2014 degrees of constipation. As the caecum becomes more
systematic review examining the role of chewing gum in dilated, the pain worsens, localising to the right-hand side
reducing postoperative ileus after caesarean section suggested with associated tachycardia. Eventually there is caecal
an incidence of approximately 12% in the control group and ischaemia, perforation and peritonitis.
that chewing gum may reduce the risk to 5%.33 There should be a high index of suspicion in postcaesarean
Ileus presents with anorexia, nausea and vomiting, absence women with progressive abdominal distension. Initial
of flatus, pain and distension worsening from time of management is with intravenous fluids, analgesia,
surgery. The symptoms are variable depending on the site of correction of electrolyte imbalances, nasogastric tube
bowel involved. Lower gastrointestinal involvement may insertion and an abdominal X-ray. Early involvement of the
feature absence of flatus with minimal distension and general surgical team and senior obstetrician is
tolerance of oral intake whereas upper gastrointestinal recommended. Imaging usually shows grossly dilated loops
involvement may feature distension, vomiting and of large bowel, especially the caecum. It has been suggested
intolerance of oral intake with the preservation of flatus.34 that for caecal diameters of less than 10–12 cm, conservative
Intravenous fluid replacement, anti-emetics and the management should be attempted with consideration of
limitation of oral intake are used to manage postoperative intravenous neostigmine. For caecal diameters of greater than
ileus. Patients with significant distension, especially if 10–12 cm, the patient should have urgent colonic
accompanied with intractable vomiting, may benefit from a decompression with a rectal flatus tube. Most patients will

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 Complications of caesarean section

recover quickly but if decompression fails or there is evidence

Caesarean section at full dilatation
of peritonitis, laparotomy and bowel resection is required.36
Some case reports suggest earlier surgical intervention at There is evidence that the incidence of second stage caesarean
smaller caecal diameters but the key to management is sections is increasing.38 These are associated with an increase
prompt recognition and general surgical input.37 in maternal morbidity, including haemorrhage, wound
The specific complications of caesarean section are extension and visceral trauma.39 Similarly, there is a higher
summarised in Table 1. risk of fetal trauma associated with difficulty in delivering a

Table 1. Complications occurring during or after caesarean section

Complication Incidence Avoidance Treatment

Postpartum Approx 5% 1. Antenatal diagnosis of abnormal 1. Uterotonic agents

haemorrhage placentation/fibroids, etc. 2. Prompt surgical repair
2. Meticulous surgical technique 3. Balloon tamponade
4. Compression sutures
5. Uterine devascularisation
6. Interventional radiology
7. Hysterectomy

Sepsis Wound: 6.8–9.7% 1. Antibiotics prior to skin incision 1. Antibiotics

Endometritis: 2. Vaginal decontamination 2. Radiological drainage
3.9–18.4% 3. Meticulous haemostasis 3. Wound exploration/debridement
4. Appropriate use of abdominal/wound 4. Re-laparotomy, debridement, wash-out
drains

Bladder injury Approx 0.1% 1. Careful peritoneal entry 1. Surgical repair

2. ?Avoiding bladder flap creation 2. Consider possibility of ureteric damage
3. Avoiding excessively low uterine incision 3. Bladder drainage
4. Cystogram 10–14 days later

Ureter injury Approx 0.4% 1. Correct for dextro-rotation prior to uterine 1. Urology opinion
incision 2. Ureteric occlusion:
2. Caution when repairing extensions and
operating near broad ligament i. Suture removal
3. Caution when repairing bladder injuries ii. Ureteric stenting
iii. Nephrostomy

3. Ureteric transection:

i. Re-anastomosis
ii. Re-implantation

Bowel injury ? 1. Careful peritoneal entry 1. General surgical assistance

2. General surgical assistance if extensive 2. Primary repair
previous surgery 3. Resection and stoma formation
3. ?Exteriorisation when suturing near
broad ligament

Postoperative ileus Approx 12% 1. Careful bowel handling 1. Exclusion of more serious pathology
2. ?Chewing gum postoperatively 2. IV fluid replacement
3. Correction of electrolytes
4. Anti-emetics
5. Gastric drainage
6. Minimise opiates

Ogilvie syndrome ? 1. As for postoperative ileus

2. Urgent surgical review
3. Consideration of neostigmine
4. Rectal flatus tube
5. Laparotomy

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 Field and Haloob

deeply impacted head. Fetal head lifting devices are under time of operation and are easily corrected either by
evaluation and have been associated with statistically the operating surgeon or by seeking assistance from
significant reductions in operating time, incision to delivery other specialties.
time and uterine extensions, although the evidence base is
limited.40 The use of such devices is not currently routine or Disclosure of interests
recommended outside of an audit or research trial.40 AF is the National Trainees’ Committee Representative for
Health Education East of England and also sits on the RCOG
Complications of caesarean section in Professional Development Committee.
resource-poor countries
Contribution of authorship
Caesarean section rates have increased rapidly in many low- and RH instigated, co-wrote and edited the article. AF researched,
middle-income countries, a trend that might have serious effects co-wrote and edited the article.
on maternal health, particularly physical and socioeconomic
consequences of caesarean section in resource-poor countries.
An analysis by Vogel et al.41 showed that caesarean section rates References
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