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Management of Wound Complications of Cesarean Delivery

7/1/2014 - William D. Po, MD

Mentor: Christopher M. Zahn, MD

Editor: Roger Smith, MD

Initial Approval 11/1/14;  Reaffirmed 5/1/16

Wound infection is the most common surgical adverse event in the United States.  It is estimated that 3-15% of cesarean deliveries have a wound complication.  Among women weighing over 200 lbs. nearly 30% experience a complication, the majority being superficial wound disruptions.

Preoperative measures that have been shown to reduce wound complications include prophylactic antibiotics given within one hour before the incision, hair removal with clippers rather than shaving, and skin preparation using chlorhexidine gluconate.

Several perioperative factors also reduce wound complications.  These include proper hand hygiene and sterile technique, shorter operative times, attention to hemostasis, careful patient temperature regulation, and adequate oxygenation and fluid replacement during surgery.  The closure of the subcutaneous tissue reduces wound complications when there is more than 2 cm of adipose tissue, and the use of subcutaneous skin closure is superior to closure with staples.

Proper assessment is critical if a wound complication is suspected.  The incision should be evaluated for erythema, warmth, pain out of proportion to that expected, and drainage of blood, serous fluid, or pus.  If the skin has separated, gentle probing can help to determine the size of any defect and confirm fascial integrity.  Seromas, hematomas, and abscesses may extend further through the subcutaneous space than visible externally.  Small seromas or hematomas may be monitored conservatively. Larger seromas, hematomas, and infected wounds should be opened. Sutures and staples should be removed as necessary based on clinical the scenario.  Devitalized tissue should be debrided, and the integrity of the fascia reassessed.  Wound cultures should be obtained if there is evidence of infection.

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.

Wound dehiscence is defined as a fascial defect, and may be associated with evisceration.  This complication often presents with profuse serosanguineous 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 a wound is infected.  After a cesarean delivery the causative organisms can be from skin or vagina, so broad spectrum coverage is indicated. 

 

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