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National Collaborating Centre for Women's and Children's Health (UK). Caesarean Section. London: RCOG Press; 2011 Nov. (NICE Clinical Guidelines, No. 132.)

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Caesarean Section.

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10Recovery following caesarean section

Postnatal advice for women who have had a caesarean section (CS) includes general and specific advice. Specific advice includes advice on CS wound care, analgesia at home, when to resume normal activities such as driving, exercise and sexual intercourse and the provision of detailed information on possible risks associated with CS birth and possible complications. Information on the risk and benefits of CS should have been discussed prior to CS however they should be reiterated again. It is outside the scope of this guideline to consider general post natal advice. General advice has been developed and published as part of randomised controlled trial (RCT) (IMPaCT study).568 [evidence level 3]

Pain

Antenatally about 60% women express a preference for a birth that is as pain free as possible and for a quick recovery.4 Assessment of pain during the immediate postoperative period is not reported in any of the RCTs. One RCT (n = 1596) report on abdominal, perineal and back pain at three months after birth.514 [evidence level 1b] Four cohort studies involving a total of 4749 women in Australia,564,569 USA570 and Scotland563 reported on pain between 2 weeks to 18 months after birth.

Three months after delivery women who had planned CS were more likely to report pain in the abdomen (RR 1.76, 95% CI 1.24 to 2.50), and pain deep inside the abdomen (risk ratio [RR] 1.89, 95% confidence interval [CI] 1.29 to 2.79) than women who had planned vaginal birth at three months after birth. Not surprisingly perineal pain is reduced in women who have planned CS (RR 0.32, 95% CI 0.18 to 0.58).514 [evidence level 1b] At three months after birth there is also no difference in reports of back pain (RR 0.93, 95% CI 0.71 to 1.22).514 [evidence level 1b] Back pain is common, 22% to 50% of women surveyed report having back pain at either 8, 16 or 24 weeks after birth. Mode of birth has not been found to affect rates of back pain.563,564,569 [evidence level 2b]

In cohort studies 60% of women who had a CS (either planned CS or CS in labour), reported having wound pain at 24 weeks after birth,563,564 [evidence level 2b]

There is little direct evidence to guide prescribing practice of analgesia after discharge from hospital for women who have had a CS with no complications. Current guidelines on post-CS wound care suggest that for mild post-CS pain paracetamol (1000 mg four times daily) should be prescribed, for moderate pain co-codamol (1 to 2 tablets four times daily) and for severe pain co-codamol with added ibuprofen (500 mg twice daily).568 [evidence level 3]

Wound care

General CS wound care advice for women includes encouraging women to take prescribed analgesia, to complete antibiotics if prescribed, to wear loose comfortable clothes and cotton underwear, to bath or shower daily, to gently clean and dry the wound well (flannels or washcloths should be freshly laundered) and only apply dressings if advised by the doctor or midwife.568 [evidence level 3]

Infection

Evidence from cohort studies report an increased risk of postpartum endometritis among women who had CS compared to those who had spontaneous vaginal birth (RR 4.51, 95% CI 4.00 to 5.09).462 [evidence level 2b] For this reason prophylactic antibiotics are prescribed during CS.463 [evidence level 1a] Overall the impact of CS on risk of infection when antibiotics are used is less clear. No difference was detected in rates of infection between women randomised to have planned CS (6.4%) and planned vaginal birth (4.9%) (RR 1.29, 95% CI 0.97 to 1.72).48 [evidence level 1a]

Midwives and doctors involved in post natal care of women who have had a CS should retain a high index of suspicion for wound infection, urinary tract infection and endometritis; they should ask the woman about wellbeing and in particular any signs of fever; assess the wound for signs of infection, separation or dehiscence; discuss pain relief requirements and plan to remove sutures or clips when appropriate.568 [evidence level 3]

Urinary symptoms

Urinary symptoms in women who have had a CS are commonly due to urinary tract infection, but can be due to stress incontinence or rarely due to urinary tract injury.

Pregnancy and childbirth are established risk factors for urinary incontinence. Urinary incontinence is the involuntary loss of urine that becomes a social or hygienic problem.571 [evidence level 4] Women who have had a CS may have urinary incontinence but the risk of incontinence following CS is reduced compared to women who have had a vaginal birth. (3 months following birth planned CS 4.5%, planned vaginal birth 7.3% (RR, 95% CI 0.62 0.41 to 0.93).514 [evidence level 1b] Five cohorts also report an increased risk of urinary incontinence among women who have vaginal deliveries compared to those who have CS.572576 [evidence level 2b]. One cohort (n = 149) did not detect any difference in urinary incontinence at 9 weeks by mode of birth.577 [evidence level 2b] Risk of incontinence increases following pregnancy (10% in the nulliparous women, 16% after CS and 21% after vaginal birth)574 [evidence level 2b]

The estimated incidence of bladder injury in women delivered by CS is 0.1% and 0.003% in women delivered vaginally (RR 36.59, 95% CI 10.43 to 128.38). Ureteric injury occurred in 0.03% of women who had CS and in 0.001% women who had vaginal birth (RR 25.22, 95% CI 2.63 to 243.50).578 [evidence level 3] In other studies the frequency is reported to range between 16 per million to 1%.579,578,580,581 Risk factors include repeat CS and peripartum hysterectomy.580,582,583 [evidence level 3] Two RCTs include bladder/bowel/ureteric injury as an outcome measure.44,48 There were no events in either group in one RCT,48 while in the other 1 of the 93 women in the planned CS group, and none of the 115 women in the planned vaginal birth group suffered this morbidity measure.44 [evidence level 1b]

Faecal incontinence

Faecal or anal incontinence has been defined as the involuntary leakage of solid or liquid faeces or gas.584 One RCT (n = 1596) asked women about symptoms of incontinence of faeces and flatus three months following birth. No difference was detected between the groups. (Incontinence of faeces 0.8% planned CS 1.5% planned vaginal birth group RR 0.54, 95% CI 0.18 to 1.62. Incontinence of flatus 10.7% planned CS, 9.7% planned vaginal birth RR 1.10, 95% CI 0.79 to 1.54).514 [evidence level 1b] Non-intention-to-treat analysis was also not different.

Four cohort studies evaluated faecal or anal incontinence according to mode of birth. In two of these studies584,585 no difference was detected in the prevalence of faecal incontinence among women who had CS and those who had vaginal birth. In the other two studies586,587 none of the women who had CS were reported to have faecal incontinence. The prevalence of faecal incontinence among women who had vaginal deliveries in these studies ranged from 1% to 23%.

Resuming activities

In one cohort study (n = 971) the extent to which bodily pain interfered with usual activities was measured 8 weeks after birth. Women who had CS were more likely to have bodily pain which interfered with usual activity.570 [evidence level 2b] At six months pain limited physical activity among women who had either CS or assisted vaginal birth when compared with women who had spontaneous vaginal birth after birth. [evidence level 2b]

The Association of Chartered Physiotherapists in Women's Health (ACPWH) suggests that women who have had a CS should wait 8 to 10 weeks before commencing vigorous exercise. We did not identify any other guidance on exercise after a CS.588 [evidence level 4]

The Driver and Vehicle Licensing Agency (DVLA) in their guide for medical practitioners as to current medical standards of fitness to drive do not specifically provide guidance on driving after CS. They provide a general statement on driving after any surgery that suggests that drivers wishing to drive after surgery ‘should establish with their own doctors when it is safe to do so’. They add that decisions regarding return to driving should consider recovery from the surgical procedure itself, recovery from the anaesthesia, distracting effect from the pain of the surgery and any resultant physical restrictions. [evidence level 4]

Sexual intercourse

A study of women in their first pregnancy reported the pre-pregnancy prevalence of sexual problems to be 38%. Sexual morbidity increased in the first three months after birth to 83%, declining to 64% at 6 months after birth.589 [evidence level 2b]

Sexual function after birth has been assessed in one RCT514 and 4 cohort studies. The measures used to assess this included resumption of sexual activity after birth514,590 and dyspareunia following birth.514,589,591 One RCT evaluated sexual function at 3 months after birth and did not detect any difference between the two groups in the proportion of women who reported (i) not having sex since the birth (RR 1.12, 95% CI 0.89 to 1.42) or (ii) having pain during sex on the most recent occasion (RR 1.03, 95% CI 0.91 to 1.16).514 [evidence level 1b]

One cohort study (n = 971) included women in their first pregnancy. No difference was detected between women who had CS and those who had vaginal birth (assisted or unassisted).570 [evidence level 2b] A smaller study from the USA (n = 66) did not detect any difference in dyspareunia at 2–8 weeks postpartum between women who had CS and those who had vaginal birth.591 [evidence level 2b] The third study reported that one month after birth women who had CS were more likely to have resumed intercourse than women who delivered vaginally.590 [evidence level 2b] The fourth study reported that dyspareunia was associated with vaginal deliveries and previous experience of dyspareunia in the first 3 months after birth. At six months there was no difference detected in rates of dyspareunia according to mode of birth589 [evidence level 2b]

Breastfeeding

Rates of initiation of breastfeeding are higher among women who had vaginal birth compared with those who had CS. However, by three to six months after birth there is no difference in breast feeding rates between the two groups.514 [evidence level 1b]

Postnatal depression

The incidence of postnatal depression is estimated to be 13%.592,593 Self report measures tend to yield higher estimates of postpartum depression than interview-based methods.593 [evidence level 2b] Depression following childbirth has been assessed by various scales including the Edinburgh Postnatal Depression Scale (EPDS),592 the Profile of Mood States (POMS),594 the Beck Depression Inventory, the Zung Depression Scale and the Center for Epidemiological studies Depression scale.593

One RCT measured postnatal depression, at 6 weeks48 (n = 2086) and 3 months514 (n = 1596). Early postpartum depression occurred in 0.3% of women in the CS group and none in the planned vaginal birth group. It is therefore not possible to estimate a relative risk measure for this outcome. At 3 months no difference was detected in postnatal depression as defined by the Edinburgh Postnatal Depression scale (EPDS) between the groups (RR 0.93, 95% CI 0.70 to 1.24). [evidence level 1b]

Six observational studies have evaluated post natal depression and mode of birth. These studies were conducted in Scotland,563 Australia,592,594,595 USA596 and Finland.597 A variety of methods have been used to assess postnatal depression and the length of follow up varies between 2 weeks to 18 months. Two studies563,594 report a higher prevalence of postnatal depression among women who had a CS in the first two weeks after birth compared to those who had a vaginal birth. However, after 8 weeks postpartum, no difference was detected in the prevalence of postnatal depression between the two groups. [evidence level 2b]

Post-traumatic stress disorder

None of the RCTs on planned mode of birth have evaluated the impact of this on post-traumatic stress disorder. Two cohort studies from Sweden examined the prevalence of post-traumatic stress disorder between 1 month and 2 years postpartum. No difference was detected in the prevalence of post-traumatic stress disorder between women who had CS and vaginal birth. Compared with women who had vaginal birth, a higher proportion of women who had “emergency” CS (OR 6.3, 95% CI 2.0 to 20.2) and those who had assisted vaginal birth (OR 4.8, 95% CI 1.5 to 15.2) had post-traumatic stress disorder at 1–2 years after birth.598,599 [evidence level 2b]

Maternal satisfaction

One RCT asked women at three months after birth about their likes and dislikes regarding the childbirth experience.514 More women in the planned CS group indicated that they liked being able to schedule their birth (RR 1.99, 95% CI 1.66 to 2.40), liked that the childbirth experience was not very painful (RR 1.18, 95% CI 1.05 to 1.31) and felt reassured about their infant's health (RR 1.13, 95% CI 1.06 to 1.20). However, fewer women in the planned CS group indicated that they ‘liked that birth was natural’ (RR 0.17, 95% CI 0.14 to 0.22), ‘liked actively participating in the birth’ (RR 0.37, 95% CI 0.31 to 0.44) and ‘liked that recovering from the childbirth experience was not difficult’ (RR 0.84, 95% CI 0.77 to 0.92). A similar proportion of women in both groups indicated that they ‘liked the method of birth that they had had’ or ‘felt reassured about their own health’. The proportion of women that reported that ‘there was nothing they liked about their childbirth experience’ was also similar in both groups. No difference was detected between the two groups with regards to either ‘ease in caring for their new infant’ or ‘adjusting to being a new mother’. Similar trends were seen for these outcomes in the non intention to treat analysis. [evidence level 1b]

One cross sectional study600 surveyed women within a week of birth in Dublin, Ireland. The CS rate in this study was 10%. 91% of women who had vaginal birth compared with 33% of those who had CS reported that they would like a similar mode of birth for future pregnancies. [evidence level 3]

Prolapse

The prevalence of genital prolapse around the menopause has been estimated at 5%. In a case control study (n = 21,449) women attending menopause clinics were examined for uterine prolapse. Previous CS was associated with a 40% reduction in the risk of developing uterine prolapse (OR 0.6, 95% CI 0.5 to 0.8).601 [evidence level 3] Another case control in the USA found that women who underwent surgery for uterovaginal prolapse were less likely to have had a CS.602 [evidence level 3]

Recommendations

NumberRecommendation
111In addition to general postnatal care, women who have had a CS should be provided with:
  • specific care related to recovery after CS
  • care related to management of other complications during pregnancy or childbirth. [GPP] [2004]
112Women who have a CS should be prescribed and encouraged to take regular analgesia for postoperative pain, using:
  • for severe pain, co-codamol with added ibuprofen
  • for moderate pain, co-codamol
  • for mild pain, paracetamol. [D] [2004]
113CS wound care should include:
  • removing the dressing 24 hours after the CS
  • specific monitoring for fever
  • assessing the wound for signs of infection (such as increasing pain, redness or discharge), separation or dehiscence
  • encouraging the woman to wear loose, comfortable clothes and cotton underwear
  • gently cleaning and drying the wound daily
  • if needed, planning the removal of sutures or clips.1 [D] [2004]
114Healthcare professionals caring for women who have had a CS and who have urinary symptoms should consider the possible diagnosis of:
  • urinary tract infection
  • stress incontinence (occurs in about 4% of women after CS)
  • urinary tract injury (occurs in about 1 per 1000 CS). [D] [2004]
115Healthcare professionals caring for women who have had a CS and who have heavy and/or irregular vaginal bleeding should consider that this is more likely to be due to endometritis than retained products of conception. [D] [2004, amended 2011]
116Women who have had a CS are at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism), so healthcare professionals need to pay particular attention to women who have chest symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf). [D] [2004]
117Women who have had a CS should resume activities such as driving a vehicle, carrying heavy items, formal exercise and sexual intercourse once they have fully recovered from the CS (including any physical restrictions or distracting effect due to pain). [GPP] [2004]
118Healthcare professionals caring for women who have had a CS should inform women that after a CS they are not at increased risk of difficulties with breastfeeding, depression, post-traumatic stress symptoms, dyspareunia and faecal incontinence. [D] [2004]

Footnotes

1

For more recent recommendations on wound care see ‘Surgical site infection’ (NICE clinical guideline 74).

Copyright © 2011, National Collaborating Centre for Women's and Children's Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK115312

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