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Today is my 14th pod of lscs now I have pain and tenderness in right lower quadrant what can it be

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post cesarean section complications right lower quadrant pain

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Right Lower Quadrant Pain & Tenderness on Day 14 Post-LSCS

Day 14 (POD 14) is a critical window - the patient is still in the early postoperative/postpartum period and several diagnoses must be considered, some of them urgent. Here is a systematic breakdown:

1. Wound-Related Causes (Most Common)

Surgical Site Infection (SSI)

  • Occurs in up to 3% of caesarean deliveries even with prophylactic antibiotics
  • Risk factors: obesity, second-stage CS, suprafascial drains, labor before CS
  • Presents: redness, warmth, induration, discharge, and tenderness at the incision - the RLQ end of the Pfannenstiel scar may be the focal point
  • 25-30% caused by Staphylococcus aureus
  • Creasy & Resnik's Maternal-Fetal Medicine, p. 960

Wound Hematoma / Seroma

  • Caused by faulty hemostasis, responds to drainage
  • Can present as a tender, fluctuant mass in the RLQ of the scar
  • Creasy & Resnik, p. 960

Necrotizing Fasciitis

  • Rare but potentially fatal consequence of wound infection
  • Obese patients are at higher risk
  • If rapid spread of erythema, skin necrosis, crepitus, or systemic toxicity - this is a surgical emergency
  • Creasy & Resnik, p. 960

2. Ovarian Vein Thrombosis (Important - Do Not Miss)

This is a classic post-cesarean complication that specifically manifests in the right lower quadrant:
  • Presents with postoperative abdominal pain and a palpable tender mass extending from the lower quadrant into the flank, usually on the right side
  • Right-sided in ~80% of cases (due to right ovarian vein anatomy and dextrorotation of the uterus)
  • Can cause fever that does not respond to antibiotics
  • Diagnosis: CT/MRI
  • Treatment: anticoagulation (heparin)
  • Creasy & Resnik's Maternal-Fetal Medicine, p. 960

3. Endomyometritis

  • Polymicrobial uterine infection presenting with abdominal pain, uterine tenderness, fever, malaise, and malodorous lochia
  • Can cause referred or radiating pain to the lower quadrants
  • Treatment: IV clindamycin + gentamicin is the gold standard regimen
  • Creasy & Resnik, p. 960

4. Appendicitis (Must Rule Out)

  • Appendicitis can occur coincidentally in the postpartum period and must always be excluded in a patient with RLQ pain and tenderness
  • Clinical signs may be atypical postpartum (uterus displaces the appendix during pregnancy and it gradually returns; by day 14 it is largely back to normal position)
  • Diagnosis: Ultrasound first, then CT if inconclusive, MRI is also an option
  • Rosen's Emergency Medicine, p. 3361

5. Urinary Tract Infection / Ureteric Colic

  • Post-CS bacteriuria occurs in ~11% of patients (related to urethral catheterization)
  • Can cause suprapubic and lower quadrant pain
  • Right ureteric colic from a stone can also present as acute RLQ pain with tenderness
  • Creasy & Resnik, p. 960

6. Bowel-Related Causes

  • Adynamic ileus - not uncommon after CS, especially if bowel was manipulated
  • Ogilvie syndrome (pseudo-obstruction of the cecum) - can cause RLQ distension and tenderness
  • Constipation - very common post-operatively; can cause focal tenderness in the RLQ (cecum/ascending colon)
  • Creasy & Resnik, p. 960

7. Other Causes to Consider

CauseKey Feature
Deep vein thrombosisLeg swelling + RLQ if involving iliac vein; occurs in 1-2% post-CS
Uterine scar dehiscenceSevere pain, uterine tenderness, abnormal bleeding
Pelvic abscessFever, systemic illness, pelvic fullness on exam
Subacute intestinal obstructionAdhesion formation post-CS, colicky pain, distension

Recommended Immediate Evaluation

  1. Examine the wound closely - infection, hematoma, dehiscence
  2. Uterine tenderness + lochia - rule out endomyometritis
  3. Vitals + CBC + CRP - fever, leukocytosis
  4. Urine analysis + culture - rule out UTI
  5. Pelvic/abdominal ultrasound - first-line imaging; assess uterus, adnexa, ovarian veins, appendix, free fluid
  6. CT abdomen/pelvis with contrast - if ultrasound inconclusive and clinical concern for OVT, abscess, or appendicitis
  7. Coagulation profile + D-dimer - if thrombosis suspected
Bottom line for clinical priority: On POD 14 post-LSCS with RLQ pain and tenderness, the most important diagnoses to rule out urgently are ovarian vein thrombosis, surgical site infection/necrotizing fasciitis, and appendicitis. Endomyometritis and UTI are common and should also be treated if confirmed. Start with wound examination, vitals, bloods, and pelvic ultrasound.
Disclaimer: This is clinical reference information. Assessment and management must be done by a qualified clinician based on the full clinical picture.
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