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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 11/1/2014;  Reaffirmed 5/1/2016, 9/5/2017

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. Other risk factors include smoking, labor, chorioamnionitis, and emergency surgery.

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

Several perioperative factors also reduce wound complications. These include proper hand hygiene, sterile technique, shorter operative time, adequate hemostasis, careful patient temperature regulation, adequate oxygenation, and fluid replacement during surgery. Repeated doses of prophylactic antibiotics may be beneficial during prolonged surgery or if there is significant blood loss. 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 separation, fascial integrity, erythema, warmth, pain out of proportion to that expected, 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 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 and sutures or staples should be removed as necessary. Wound cultures should be obtained if there is evidence of infection. Devitalized tissue should be debrided and if necrotizing fasciitis is suspected, aggressive surgical and antibiotic therapy 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.

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, or genitourinary or gastrointestinal tract, so broad spectrum coverage is indicated.

Further reading:
Kawakita T, Landy H. Surgical Site Infection After Cesarean Delivery: Epidemiology, Prevention and Treatment. Maternal Health, Neonatology, and Perinatology. 2017;3:12

 

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