Wound Infection
Merita O’Sullivan and Susan Drummond
Definition
A.Infection may occur at the site of the cesarean section incision, an episiotomy, or a genital tract laceration. Most wound infections become clinically apparent 5 to 6 days after delivery.
Incidence
A.Approximately 4% of clean wounds and 35% of grossly contaminated wounds become infected. Rates of infection after cesarean delivery range from 5 to 30 times more than vaginal delivery. To reduce this risk, a single IV dose of a narrow-spectrum antibiotic (cefazolin, ampicillin) should be given within 60 minutes before making the skin incision to all women undergoing a cesarean section. For women with a penicillin allergy, a dose of both clindamycin 900 mg and gentamycin 5 mg/kg IV can be used for prophylaxis.
Pathogenesis
A.A variety of organisms may be responsible. Examples include Staphylococcus or Streptococcus species and Gramnegative organisms, Gram-positive cocci and Bacteroides, Clostridium species, or Escherichia coli.
B.Early wound infections, occurring in the first 24 to 48 hours, are usually caused by group A or B beta-hemolytic streptococcus and are characterized by high fever and cellulitis.
C.Delayed infections are more likely caused by Staphylococcus epidermis or aureus, E. coli, Proteus mirabilis, or cervicovaginal flora.
Predisposing Factors
A.Obesity.
B.Anemia.
C.Malnutrition.
D.Smoking.
E.Diabetes.
F.Substance abuse.
G.Immunosuppression.
H.Poor hygiene.
I.Lower socioeconomic status.
J.Lack of preoperative prophylactic antibiotics.
K.Chorioamnionitis.
L.Blood transfusion.
M.Anticoagulation therapy.
N.Second-stage cesarean section.
O.Subcutaneous hematoma.
P.Cardiovascular disease.
Q.Previous surgery.
R.Prior irradiation.
Common Complaints
A.Redness, heat, swelling, and tenderness at site.
B.Foul-smelling drainage.
C.Elevated temperature.
Other Signs and Symptoms
A.Fever and chills.
B.Edema.
C.Foul-smelling purulent discharge.
D.Leukocytosis.
E.Localized erythema, induration, and warmth at the incision site.
F.Pain at the incision site.
G.Wound separation may occur.
Subjective Data
A.Elicit onset, duration, and course of symptoms.
B.Review medical history (see section Predisposing Factors
); antepartum history for complications such as diabetes; intrapartum complications for prolonged rupture of membranes, fever in labor, use of internal monitoring devices, length of labor, or frequent cervical examinations.
C.Question the patient regarding hygiene at wound site since delivery, including the frequency of changing peri-pads, use of sitz baths, and showering.
D.Question the patient regarding drainage from wound or episiotomy, noting color, amount, and odor.
E.Review signs and symptoms of breast engorgement and urinary tract infection (UTI).
F.Review vaginal delivery for third- and fourth-degree episiotomy or laceration. Third- and fourth-degree vaginal lacerations/episiotomies have approximately a 25% incidence of wound breakdown and a 20% incidence of wound infection. In comparison, the incidence of infection in all types of perineal wounds is 0.1% to 5%.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure (BP).
B.Examination should not be limited to the incision site. A complete physical is needed to evaluate breasts, lungs, hematomas, and concurrent UTIs.
C.Inspect: Examine the incision site (episiotomy or abdomen) for drainage, redness or edema, and intactness.
D.Palpate:
1.Perform breast examination.
2.Palpate suture line (episiotomy or abdomen). Probe incision with cotton-tipped swab to evaluate for hematoma, cellulitis, and/or pus.
3.Palpate all abdominal quadrants.
4.Palpate the vagina to rule out concealed hematoma.
E.Auscultate: Auscultate the heart and lungs.
F.Percuss: Percuss the back to assess costovertebral angle (CVA) tenderness.
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Blood culture (optional).
C.Culture of infected area.
D.Urinalysis, culture, and sensitivity, if indicated.
Differential Diagnoses
A.Wound infection.
B.Impending dehiscence. If serosanguinous drainage is noted after the first 24 hours, dehiscence is possible.
C.Episiotomy breakdown.
Plan
A.General interventions:
1.The wound may need to be opened and cleaned.
2.For an infection at a cesarean section site, wound irrigation and dressing changes several times a day may be necessary.
3.Home health referral may be needed.
B. 
See Section III: Patient Teaching Guide Wound Infection.
C.Dietary management:
1.No dietary restrictions are recommended; encourage the patient to eat well-balanced meals.
Increase protein in diet for wound healing.
2.Instruct the patient to increase fluid intake; have her drink at least 10 to 12 glasses of liquid a day.
D.Pharmaceutical therapy:
1.Topical antiseptic and antimicrobial agents (povidone-iodine, sodium hypochlorite, hydrogen peroxide) should be avoided since they may be toxic to fibroblasts and impede wound healing.
2.Empiric treatment is started using broad spectrum antibiotics with coverage of Gram-positive cocci from the skin as well as the expected flora at the wound site:
a.Augmentin 875 mg twice a day for 7 to 10 days.
b.Clindamycin 450 mg every 6 hours for 7 to 10 days; safe for breastfeeding.
c.Cefoxitin 1 to 2 g by IM injection or IV infusion every 6 to 8 hours; safe for breastfeeding.
3.Definitive antimicrobial treatment is guided by the clinical response of the patient and the results of the Gram stain and wound culture and sensitivity, when available.
4.Acetaminophen (Tylenol) when required for elevated temperature.
Follow-Up
A.Reevaluate the patient in 48 hours to assess wound healing.
Consultation/Referral
A.Consult a physician for evaluation and possible surgical closure.