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7/1/2014

Management of Wound Complications of Cesarean Delivery

Preoperative measures that reduce wound infection include weight-based prophylactic antibiotics given within one hour before the incision, the addition of azithromycin when indicated, hair removal with clippers rather than shaving, and skin and vaginal cleansing. Preoperative showers should be encouraged before elective procedures.

Several perioperative factors also reduce wound complications.  These factors include proper hand hygiene, sterile technique, shorter operative time, adequate hemostasis, patient temperature regulation, adequate oxygenation, perioperative glycemic control and fluid replacement during surgery. Repeated doses of prophylactic antibiotics may be beneficial during surgery over 4 hours (based on cefazolin’s half-life) and/or if blood loss is greater than 1500 mL. Closure of the subcutaneous tissue reduces wound complications when there is more than 2 cm of adipose tissue. The use of subcutaneous skin closure is superior to closure with staples.

If a wound complication is suspected, the incision should be evaluated for separation, fascial integrity, erythema, warmth, disproportionate pain, and drainage of pus, blood, or serous fluid.  If the wound edge has separated, probing with a sterile Q-tip can help to determine the size of defect and confirm that the fascia is intact. Seromas, hematomas, or abscess cavities may extend farther through the subcutaneous space than visible externally. Small seromas or hematomas may be observed. Larger seromas, hematomas, and infected wounds may need to be opened by removing sutures or staples as necessary.  Wound cultures should be obtained if there is evidence of infection. Devitalized tissue should be debrided. If necrotizing fasciitis is suspected, aggressive surgical debridement and broad-spectrum antibiotics should be initiated immediately.

If infection is present, irrigation reduces the bacterial load.  Water or warm saline may be used at low pressure.  The addition of cleansing solutions is not necessary and may hinder wound healing.  The wound should be irrigated at the time of initial evaluation and repeated when dressings are changed. Showering is also effective.

Appropriate wound dressings can improve wound healing.  Modern dressings maintain moisture and provide some degree of occlusion.  A number of dressings are available, including hydrogels, foams, alginates, and colloids.  Different dressings may be more appropriate at different stages of wound healing.  Large wounds and wounds that are clearly infected may need to be left open and packed with saline-moistened gauze until wound closure or an occlusive dressing can be used.  Gauze dressings are usually applied in the initial stages of wound management.  Negative pressure wound therapy typically uses a foam dressing with the application of negative pressure and may enhance wound healing, but are not likely of benefit for prophylaxis.

Wound dehiscence is defined as a fascial defect and may be associated with evisceration.  This complication often presents with profuse serosanguinous discharge, although the skin may be intact initially. Complete fascial disruption is a surgical emergency and requires wound exploration and repair. The skin may be closed or left open depending on the characteristics of the wound.  

Antibiotics are indicated if the wound is infected.  After cesarean delivery the causative organisms can be from skin, genitourinary tract or gastrointestinal tract, so broad spectrum coverage is indicated.

Further reading:

Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. doi: 10.1001/jamasurg.2017.0904.

Committee on Practice Bulletins-Obstetrics; ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol. 2018 Sep;132(3):e103-e119. doi: 10.1097/AOG.0000000000002833.

Kawakita T, Landy H. Surgical Site Infection After Cesarean Delivery: Epidemiology, Prevention and Treatment. Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. eCollection 2017.

Initial Approval November 2014; Reaffirmed May 2016, September 2017, October 2020; Revised March 2019. Revised November 2020. Minor Revision July 2022

 

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