BIRTH-RELATED

WOUNDS TE
LA D
RISK, PREVENTION E
AND MANAGEMENT

W
TH R
OF COMPLICATIONS

OUNDS
AFTER VAGINAL
AND CAESAREAN
R
SECTION BIRTH
I
B
 Charmaine Childs (Editor), BNurs, MPhil, PhD, Professor of Clinical Science, College of Health, Wellbeing and Life Sciences,
Sheffield Hallam University, UK
Kylie Sandy-Hodgetts (Co-Editor), BSc, MBA, PhD, Senior Research Fellow/Senior Lecturer, Faculty of Medicine, School of
Biomedical Sciences, University of Western Australia; Director, Skin Integrity Research Unit, University of Western Australia,
Perth, Australia
Carole Broad, MCSP, Clinical Specialist Physiotherapist in Pelvic Health, Department of Physiotherapy, Cardiff and Vale UHB,
Cardiff, Wales, UK
Rose Cooper, BSc, PhD, PGCE, CBiol, MRSB, FRSA, Former Professor of Microbiology at Cardiff Metropolitan University,
Cardiff, Wales, UK
Margarita Manresa, RNM, MScNurs, PhD, Maternal and Fetal Medicine, Hospital Clinic of Barcelona, Barcelona, Spain
José Verdú-Soriano, RN, MScNurs, PhD, Professor of Community Nursing and Wound Care, Department of Community
Nursing, Preventive Medicine, Public Health and History of Science, Faculty of Health Sciences, University of Alicante,
Alicante, Spain

Expert reviewer: Dr Sara S Webb, FRCM, Head of Information and Research Services, Royal College of Midwives, UK
Editorial support and coordination: Anne Wad, EWMA Secretariat
Corresponding author: Charmaine Childs ([Link]@[Link])

The document has been supported by unrestricted educational grants from: Abigo, Convatec, Essity, Flen Health

© EWMA 2020

All rights reserved. No reproduction, transmission or copying of this publication is allowed without written permission.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of the European Wound
Management Association (EWMA) or in accordance with the relevant copyright legislation.

Although the editor, MA Healthcare Ltd and EWMA have taken great care to ensure accuracy, neither
MA Healthcare Ltd nor EWMA will be liable for any errors of omission or inaccuracies in this publication

Published on behalf of EWMA by MA Healthcare Ltd

Editor: Negin Shamsian
Managing Director: Anthony Kerr
Published by: MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London, SE24 0PB, UK
Tel: +44 (0)20 7738 5454 Email: [Link]@[Link] Web: [Link]

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Contents
Introduction4 Complications associated with the
Definitions 4 caesarean section incisional wound 18
Scope 4
Childbirth through the ages 5 Invasive infections affecting deep tissue
The health and economic impact of  and organ space 18
obstetric infections and complications 6 Necrotising fasciitis 18
Birth-related infection in the 21st century 6 Endometritis 19
Pelvic anatomy and pelvic function 6 General treatment principles and clinical
The pelvic floor 7 management options 19
Impaired pelvic floor function 7
Perineal injuries 19
Perineal wounds-tears, lacerations 
Caesarean section wounds 20
and episiotomy 7
The use of wound care dressings
Caesarean section birth 9
and the scientific and clinical evidence base 20
Methods for caesarean section incision 9
Risk factors for wound complications 10 Topical issues and controversies 21
Risk factors for complications of caesarean section The role of honey in wound care 21
incisional wounds 10 The impact of birth-related wounds
Surgical risk factors 11 on the economy 22
Lifestyle factors and pre-existing comorbidities 11 The use of antimicrobials after childbirth 26
The impact of obesity postpartum 11 Antimicrobials associated with vaginal delivery 26
Childbirth-related perineal trauma and infection 12 Perioperative antibiotic use for caesarean section 26
Natural microbial flora of the skin 12 The role of the midwife 28
Natural microbial flora of the female  Antenatal education 29
genital tract 13 Postnatal education 29
Common pathogens of the female  Going home 29
genital tract 14 Educating women in personalised care 30
Maternal mental health 31
Postpartum wound infections 15
Patient portraits 31
Infections associated with perineal tears
and episiotomy 15 Ellen's story 31
Wound assessment 15 Loretta's story 32
Assessment of perineal wounds 16
The REEDA scale 16
Victoria's story 33
The impact of wounds on the patient 17 Key points 34
Pain 17 Summary and future perspectives  35
Long-term consequences 17
Granuloma and overgranulation of tissue  Appendix 1. Patient guide 36
after CRPT 17 References37

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Birth-related wounds
Introduction This document originated from a growing interest
Childbirth is one of life’s great miracles. It is a by many EWMA stakeholders in the science and
time of joy and at times fear, exhilaration and clinical management of birth-related wound
relief, with the spectrum of human emotions complications. An expert group was established to
for some women experienced simultaneously. produce an evidence-based consensus document
Notwithstanding the physical toll childbirth takes for healthcare workers. The group consists of
on the female body, wound complications related representatives from the EWMA Council and EWMA
to the birth can occur, often an unfortunate Cooperating Organisations. Based on a literature
result of multiple factors related to injury to skin search conducted by the document authors and
and deeper tissues. Birth wound complications, the EWMA secretariat, together with input from
such as trauma to the perineum and vagina key EWMA stakeholders, a short description of the
(and, in the event of birth by caesarean section, document aim, objectives and scope was developed
breakdown and/or infection of the surgical during the first quarter of 2019.
wound), have a considerable impact on a
woman’s physical and mental wellbeing. Despite The opinions expressed in this document have
advances in our knowledge of asepsis, midwifery, been reached by consensus of the author group
obstetric surgery and wound healing, birth-related based on professional, clinical and research
wound complications still occur. The greater expertise, as well as the experience and expert
challenges faced by healthcare professionals are in review by peers. The clinical guidance provided
the clinical management of tissue trauma and the in the document is based on critical analysis
physical and emotional wellbeing of the mother. and synthesis of published guidelines, literature
reviews and evidence-based recommendations as
Wound-related complications after delivery well as consensus-driven expert opinion.
may last for many years, with the more serious
consequences requiring reconstructive surgery and Definitions
patient rehabilitation. Attention is also required to For the purpose of this document, birth wound
address a woman's needs in reducing physical and complications are reviewed as arising from:
psychological pain and distress arising from birth-
related wounds and infection-related complications. • Childbirth-related perineal trauma (CRPT)
This is especially relevant, as we enter an era of spontaneous trauma and/or surgical cut
antimicrobial resistance where reliance on life-saving (episiotomy) to the perineal tissues during
antibiotics to prevent or treat infections may no vaginal childbirth
longer be guaranteed as an effective line of defence. • Surgical incision of superficial and deep tissue
Overuse, as well as misuse, of antibiotics is now a of the lower abdomen in the performance of
serious concern globally. Moreover, the economic planned or emergency caesarean section.
costs of wound care impose a considerable burden
on healthcare systems, which require strategies Scope
to improve wound assessment and underpin the This document is intended for healthcare
rationale for evidence-based treatment. practitioners with an interest in the care and

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management of women before, during and after
childbirth. It is anticipated that the readership
will primarily be qualified hospital-based as
well as community-based midwives, wishing to
consolidate their knowledge, as well as to update
their practice. Among the wider healthcare
community, the document will be of interest
to undergraduate and postgraduate students as
well as experienced healthcare professionals in
leadership roles, where the strategic vision of the
department is to close gaps in knowledge and
to assist in policy decisions for the delivery of
evidence-based healthcare.
Dr Ignaz Semmelweis, aged 42 in 18601
This document informs readers about the key Ignaz Semmelweis observed that hand washing in chlorinated lime
issues relating to birth-wound complications and solution between autopsy work and the examination of patients
their management by providing: reduced the occurrence of puerperal fever in the obstetric clinic
at Vienna General Hospital over a period of a year (1847). He
subsequently published his findings and is a recognised pioneer of
• A brief historical overview of complications antiseptic policy.
in childbirth
• Aetiology of birth-related complications Historical accounts of the practice of midwifery
• Discussion of risk factors and the impact of are recorded as early as the Ebers Papyrus (circa
wound infection 1550 BC) and describe birthing attendants
• Clinical management strategies assisting in delivery.5
• Wound dressings
• Personal 'vignettes' from women about the During the middle ages, women would often
experience and impact to wellbeing of birth- prepare their last will and testament before giving
related wound complications. birth.6 The most common cause of death after
childbirth was childbed fever. Early accounts of
Childbirth through the ages childbed or puerperal fever were documented by
Childbirth, also known as labour or delivery, is Hippocrates in the fourth century.7 One of the
where a pregnancy ends by the delivery of one first interventions to successfully reduce mortality
or more babies passing through the vagina or rates of childbed fever during the eighteenth
by caesarean section. Historically, the mother
2
century was improved hospital cleanliness.8
was supported by other women during the
labour, and delivery and was exclusively the In 1843, Oliver Wendall Holmes collated information
domain of women.3 The presence of physicians about puerperal fever and formulated eight measures
and obstetricians was rare and was only called to prevent it.9 However, in 1847 Ignaz Semmelweis,
for if the midwife had exhausted all measures. 4
a Hungarian physician and scientist discovered
Midwifery training began in European cities the infectious nature of puerperal fever and its
during the 1400s with the advent of obstetrics transmission route to women in labour from the
as a medical speciality occurring during the late hands of physicians working in Vienna General
eighteenth century. Hospital. There were two obstetric wards in the

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hospital: one was a teaching ward for physicians and multidisciplinary team of specialists. Complications,
medical students, and the other was managed by both physical and psychological can arise as a
midwives. Semmelweis observed that the mortality consequence of the birth itself, whether by vaginal
rate in the teaching ward was three times higher delivery or by caesarean section. In the event of
than that in the midwives’ ward. Whereas physicians tissue damage leading to a wound, be it a surgical
conducted examinations of women who had died wound infection, dehiscence or due to CRPT, all
of childbed fever and then attended women in their such complications are potentially preventable.
lying-in clinic after simply washing their hands When SSIs occur as a result of caesarean section,
with soap and water, midwives did not conduct they impose an incremental financial burden on
postmortems. After introducing hand scrubbing healthcare resources.14 With close to 141 million
with chlorinated lime solution following autopsies, births reported globally during 2015,15 typically in
the mortality rate of women in the teaching ward hospital in higher income countries,16 or at home
subsequently reduced to a rate comparable with with an attendant providing support in lower-
that of the midwives’ ward. These observations
10
income countries,17 infections during childbirth
led to the foundations of contemporary antiseptic present a significant risk for mothers.
policy. Importantly, it was not until the late 1800s,
after the establishment of the germ theory and the Birth-related infection in the 21st century
work of Joseph Lister, that practitioners understood Unfortunately, puerperal sepsis or postpartum
how to halt contamination and spread of infection infection is still the leading cause for morbidity
through hand washing and the use of carbolic and mortality after childbirth.18 Although the risk
acid for antisepsis in surgery. Antisepsis is now the of death in childbirth in developed countries is
central tenet of infection control globally. Preventing now 40–50 times lower than in the early years
hospital-acquired infections (HAIs) presents a major of the 20th century (and before the introduction
challenge to health systems. of antibiotics),19 most of the estimated 75,000
maternal deaths occurring worldwide each year
The health and economic impact of are a result of infections recorded in low-income
obstetric infections and complications countries.20–22 Global estimates for 2017 indicate
Across the world, healthcare costs are rising. that 810 women died every day from pregnancy- or
The focus for healthcare systems must be on childbirth-related complications,23 with infection
sustainability as well as person-centred care. In the third highest cause of maternal mortality after
high-income countries with lower birth rates, the haemorrhage and hypertensive disorders.24
cost of care in hospital and the community has
escalated with birth-related healthcare-associated Childbirth, whether by vaginal birth or
complications, the unintended sequelae of birth. by caesarean section can bring significant
While birth rates are falling in high-income psychological problems and functional morbidity
countries,11 the greatest challenge for low middle- as a consequence of lingering and, often,
income countries (LMICs) with high birth rates is distressing symptoms, many of which originate
to provide good quality care within the economic with a wound that later becomes infected.
climate of the nation.12 Furthermore, with the Understanding the care and management of
rising number of women of childbearing age women with wounds arising as a consequence of
with chronic diseases, obstetric complications giving birth should be underpinned by knowledge
and poor psychological wellbeing is becoming of pelvic anatomy and function, a first step in the
more prevalent,13 demanding care from a appreciation of the aetiology of perineal trauma.

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 Female Pelvic Floor Anatomy

Pelvic anatomy and

pelvic function Ischiocavernosus
Ischiocavernosus

The pelvic floor Urethral orifice

Urethral orifice

The function of the pelvic floor muscle group (Fig. 1)

Vagina
Vagina Bulbocavernosus
Bulbocavernosus

is to support the pelvic organs and maintain both

Transversus perinei
Transversus perinei
urinary and faecal continence. The pelvic floor also Perineal body
Perineal body

plays a part in providing spinal stability and has a External anal

External anal Sphincter
Anus sphincter
role in sexual function.25 However, this muscle group Anus

Deep levator
is often injured during childbirth, and can cause Deep Levator Ani
ani
deterioration in muscle function.26 Extensive perineal
trauma also increases the risk of wound infection.
Fig 1. Anatomy and principle muscles of the pelvic floor
Impaired pelvic floor function
The integrity of the perineal body, the pelvic Tears and lacerations can be superficial as well as
floor muscles as a whole, including the internal deep; the latter involving acute muscle trauma,
and external sphincters, is often compromised oedema, avulsion injury and haematoma.29 Injuries
during childbirth. Perineal wound infection, due to perineal tears are classified on the basis of
especially when coupled with wound dehiscence, severity, from first to fourth degree (Fig. 2, Table 1).
results in scarring and muscle dysfunction. Faecal A first-degree tear involves vaginal mucosa and
incontinence can be a devastating consequence connective tissue only, while second-degree tears
of childbirth. More than one in 10 women may involve the underlying perineal muscles of the
experience some form of faecal incontinence superficial pelvic floor muscle group, and include
after childbirth. A survey of 21,824 women in bulbospongiosus, and the superficial and deep
Oregon, US, with 8,774 respondents, reported transversus perinei.
46% of all women, following vaginal delivery,
experienced postpartum fecal incontinence, with Third- and fourth-degree tears are classed as an
38% reporting incontinence of flatus.27 Almost obstetric anal sphincter injury (OASI).30 In a third-
half (46%) of all women with postpartum faecal degree tear there is a partial or complete disruption
incontinence reported incontinence of stool, of the anal sphincter muscles, which may involve
and 38% reported exclusively incontinence of either the external anal sphincter (EAS) and/or the
flatus. Approximately 46% reported onset of internal anal sphincter (IAS) muscles. A fourth-
incontinence after delivery of their first child.27 degree tear is defined by a complete rupture of the
anal sphincter muscles also involving the rectal
Perineal wounds: tears, mucosa (Fig. 2). All CRPT should be immediately
lacerations and episiotomy examined and repaired, with OASI requiring
A perineal wound can occur as a result of a tear or surgical repair in theatre under spinal anaesthetic,
laceration inside the vagina, the vulva, clitoris and with follow-up by specialist postnatal services
labia (Figs 2 and 3). Approximately 85% of vaginal dedicated for women with perineal wounds.30
births are affected by childbirth-related perineal
trauma (CRPT), either spontaneously or as a result The overall prevalence of third- and fourth-
of an episiotomy ([Link]/en/patients/ degree tears is approximately 4–5% among
tears/tears-childbirth/).28 primiparous women.31 A prospective observational

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 study by Smith et al32 of 2754 women having a
singleton, vaginal birth showed that multiparous
women (birth of more than one child) were
more likely to have an intact perineum (31.2%,
453/1452) compared to nulliparous women
(9.6%, 125/1302).32 The risk of spontaneous
perineal tears at subsequent deliveries increases
First-degree perineal tear Second-degree perineal tear
with the presence and the severity of perineal
trauma at the first delivery.33 While the incidence
and causes of CRPT are known, the subsequent
acute complications that occur are not so well
reported. Without standardised treatment
protocols or national guidelines, and with limited
published research into the management of
Third-degree perineal tear Fourth-degree perineal tear CRPT wounds, there remains a lack of knowledge
and, consequently, no consensus on the care of
perineal trauma for this group of women.
Fig 2. Grades of perineal tears. Redrawn from: Sydney Pelvic Floor
Health ([Link]

A B C D

E F G H

Fig. 3. Perineal trauma due to childbirth. (A) Acute postnatal injury showing swelling and haematoma. (B) Acute injury and associated infection;
(C) and (D) Postnatal wound dehiscence and infection. (E) Episiotomy and wound dehiscence with suture material visible. (F) Poor perineal
wound healing. (G) Acute trauma of perineum with wound dehiscence and infection. (H) Delayed healing episiotomy

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Table 1. Perineal tears and mortality rate, with close to 8% of newborns
lacerations during childbirth failing to survive beyond 1 week.22

Degree Definition
The Organisation for Economic Co-operation
First Injury to vaginal mucosa or perineal skin only
and Development (OECD) highlights that
Second Injury to vaginal mucosa or perineal skin and
superficial perineal muscles while caesarean delivery is required in some
Third Injury to anal sphincter muscles and circumstances, the benefits of caesarean versus
subdivided into: vaginal delivery for normal uncomplicated
• 3A: <50% of external anal sphincter muscles deliveries are debatable. Caesarean delivery
are injured
results in increased maternal mortality and
• 3B: >50% of external anal sphincter
muscles are injured maternal and infant morbidity.36 It is also
• 3C: External and internal sphincter associated with increased complications for
muscles are injured subsequent deliveries, as well as increased
Fourth Injury involving external and internal anal financial costs. This raises questions about the
sphincter muscles and anal epithelium
appropriateness of caesarean births without
Source: Royal College of Gynaecologists and Obstetricians30
evidence of significant health benefit for the
woman if not medically required.37 OECD data
By contrast to accidental lacerations and tears systems as well as the literature indicate that
during vaginal birth, an episiotomy is a deliberate the number of caesarean sections performed
surgical incision of the perineum and the worldwide is increasing (Fig. 4).34
posterior vaginal wall. It is usually performed
by an obstetrician during the second stage of Methods for caesarean section incision
labour during instrumental birth. Episiotomy Caesarean section surgery involves an incision to
provides a rapid additional space within the birth the skin and underlying tissues to facilitate the
canal (Fig. 3). delivery of a baby. Early accounts of birth by this
method attribute the term 'caesarean' to Julius
While vaginal birth remains the major mode Caesar’s decree that 'the body should be cut open'
of delivery, caesarean section can be a planned in an attempt to deliver the baby of a dead or
(elective) or emergency procedure. dying women.38 Caesarean section operations on
living women were performed during the 19th
Caesarean-section birth century to save the life of the mother as well as
Caesarean section is the most common surgery the baby. Today, caesarean section is performed
among women worldwide, with the global rate as an emergency life-saving operation either for
rising. In a recent meta-analysis, Sobhy et al
34 35
mother and/or infant, or as a planned procedure.
reported the risk of maternal death after caesarean
section at 7.6 per 1000 procedures (95% CI There are a number of incisions that can be used
6.6–8.6) with the highest burden in sub-Saharan in the abdominal region for caesarean section
Africa. In LMICs, one in every 100 women dies (Fig. 5). The more commonly used method of
after caesarean section whereas in high-income incision during the 20th century was vertical
countries, there are eight maternal deaths per (from just below the navel to just above the pubic
100,000 caesarean sections. Maternal mortality in bone); however, this is usually reserved for breech
LMICs is 100 times greater than in high-income or preterm babies. A lower (uterine) segment
countries.35 This is further reflected in the infant caesarean section (LSCS) is the most common

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 hysterectomy, and later adapted for caesarean
Caesarean sections
Total per 1000 live births, 2017 section, had some advantages: less fever, reduced
pain and analgesic requirements, less blood loss,
Czech Republic and a shorter duration of surgery and hospital
Denmark stay.41 The curvilinear incision, below the arcuate,
Ireland in the Pfannenstiel technique produces a lower
Netherlands positioned scar. From a cosmetic viewpoint, its
New Zealand advantage is that it leaves an almost imperceptible
Israel scar because it lies in a skin crease.42
Norway
Iceland
Finland Risk factors for
Sweden wound complications
Lithuania Risk factors for complications of
Estonia caesarean section incisional wounds
France Wound healing is distinctly shorter, more efficient
Belgium and organised when achieved through the process
Slovenia of primary intention.43 Wound complications
Latvia are multifactorial resulting in wound separation
Spain without infection,44 superficial and deep wound
United Kingdom
infection45 and rarely, necrotising fasciitis.43
Canada
Infection, inhospitable characteristics of the host
Austria
(such as vascular or chronic disease), suboptimal
Luxembourg
perioperative conditions (hypothermia), and
Slovak Republic
surgical technique that injures tissue can all
Germany
impede the normal phases of wound repair.
Switzerland
Here, risk factors for post-caesarean wound
Italy
complications will also impede wound healing.43
Hungary
Poor wound healing, due to the onset of
Poland
infections, seroma, abscesses and haematoma, is
Korea
often associated with multiple risk factors, some
Turkey
of which are modifiable and others that are not.46–52
0 50 100 150 200 250 300 350 400 450 500

Fig. 4. Total caesarean sections performed by country. Broadly, risks for wound complications include
Data source: OECD39. Reproduced with permission patient and procedural-related factors and
circumstances that should be incorporated into
type of surgical incision to deliver the baby. This the risk assessment plan (Fig. 6). Evidence-based
type of incision results in less blood loss. 40
interventions should be implemented in clinical
practice to reduce wound complications after
A review conducted by Saha et al (2013)41 of caesarean section, but short stays in hospital,
two surgical incision methods, the Pfannenstiel typically 1–2 days, mean that many women who
and Joel-Cohen technique, revealed that the develop a post-surgical birth wound complication
Joel-Cohen incision, originally described for do so in the community.53,54

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Surgical risk factors Umbilicus
It has been reported that obstetrician experience
may be related to SSI risk, particularly where the Midline vertical
lead obstetrician performing the procedure was not Maylard
a consultant.56 There are several publications with
evidence-based recommendations for prevention.56,57 Joel-Cohen
While national guidelines for SSI exist with58 Pfannenstiel
recommendations for assessing the wound for signs Pubic bone
of infection, there remains no ‘gold standard’ or
consensus for this aspect of clinical care.

Fig. 5. Methods for surgical incisions used in caesarean section.

Other risk factors include the type of anaesthesia, Redrawn from [Link]
duration of surgery, lack of antibiotics or
inappropriate timing or choice of prophylaxis,
suture materials, operating room temperature,
obstetrician experience and the surgical techniques
used. Risk factors such as incision length,
Lifestyle factors
corticosteroid administration and pre-pregnancy
body mass index (BMI) have also been studied.46

Life-style factors and

pre‑existing comorbidities
Patient-level risk factors such as pre-existing
Pre-existing
comorbidities and lifestyle factors, which Surgical factors
comorbidities
may be modifiable, include diabetes, obesity,
hypertensive disorders of pregnancy, previous
caesarean delivery and tobacco use. Recognising
that some risk factors may not be modifiable
presents a challenge for the obstetrician and the Fig. 6. Conceptual framework for surgical
clinical management team. For example, in a wound complications.54
large multicentre cohort study of 15 hospitals
participating in the UK Health Protection Agency obesity is a significant determinant of health
(HPA) Surgical Site Infection Programme, Wloch outcomes for women who develop an SSI.
et al observed an overall SSI rate of 9.6%, with
56

obesity representing an independent risk factor The impact of obesity postpartum

for SSI. The odds ratio for infection more than The prevalence of obesity (BMI >30kg/m2) is
doubled for those with a BMI 30–35kg/m2, and increasing worldwide and poses a major challenge
a BMI >35kg/m presented the highest risk for
2
to public health.60 In Europe, over 50% of women
SSI (OR 2.4; 95% CI 1.7–3.4 and OR 3.7; 95% CI are overweight, approximately half of whom (23%)
2.6–5.2, respectively). The risk of SSI for women are obese.62 Obesity prevalence rates are estimated
with diabetes was also high at 15.6% (95% CI to be as high as 30% in pregnant women. Research
11.0–21.1%) compared with the overall rate of has shown that the proportion of pregnant women
9.6% (95% CI 8.7–10.6%). Thus, the impact of with obesity has doubled over the past decade,

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from around 22% in 2010 to 44% in 2018.63 In prolonged rupture of membranes,70 use of
addition, approximately 40% of women gain an catgut to suture the tear70 and experience of the
excessive amount of weight during pregnancy in practitioner.70 Johnson et al (2012)67 concluded
Western countries.62 The high level of maternal that operative vaginal births (forceps or vacuum-
obesity has implications for maternity and neonatal assisted) and episiotomy may predispose women
service provision. The risk that obesity imposes to perineal wound infection. Breakdown of a
for outcomes after surgery is widely recognised laceration or episiotomy was more likely with
across the specialty.64,65 A study53 of obese women OASI, operative vaginal births, and meconium-
(BMI ≥30kg/m2) who gave birth by caesarean stained liquor.71–73
section, found that presentation to the community
physician with signs of superficial wound infection For higher order lacerations (third- and fourth-
occurred 6–24 (median 18) days after surgery. In degree tears/laceration), Jallad et al74 found
this cohort of high-risk women, 28% received smoking, nulliparity, operative delivery, repair
a clinical diagnosis of wound infection with a by a midwife and use of chromic sutures were
prescription for antibiotics. Wound swabs taken independent risk factors for breakdown of a
at the time of the community visit were, in the perineal laceration repair after vaginal delivery.
majority of cases, negative for pathogenic micro- Wilkie et al75 found that chorioamnionitis was
organisms. However, for those women with a a risk factor for higher-order lacerations, while
clinical diagnosis of SSI, anaerobes (typically heavy forceps deliveries, episiotomy and the need for
growth) were noted in laboratory reports. It is not narcotic pain medications postpartum were
clear whether anaerobes had a role in SSI because risk factors for perineal wound breakdown.
pathology laboratories do not usually undertake Gommesen et al31 found that BMI >35kg/m2
full characterisation of the organism as they are was associated with a seven-fold risk of CRPT
difficult to grow, identify and to perform antibiotic infection, while episiotomy was associated with a
susceptibility testing. If anaerobes are reported in three-fold risk.
swabs taken from caesarean section wounds (and
this applies also to CRPT), clinicians will usually The reported prevalence of dehiscence in
prescribe metronidazole as there are few suitable perineal tears ranges from 4% to 20%. The
antibiotics available. In the presence of a breach large variation may be explained by the lack of
of the skin barrier, together with localised vascular standardised definitions of postpartum perineal
insufficiency, anaerobes can lead to surgical wound wound infection and dehiscence.31
infection.66 The relevance of anaerobe species to
wound infection are discussed more fully below.
Natural microbial
Pregnancy-related risk factors that are generally flora of the skin
not modifiable include emergency or unscheduled The skin is not a sterile structure. It has an
caesarean section delivery. indigenous microbiota dominated by Gram-
positive bacteria. These include the genera
Childbirth-related perineal trauma Staphylococcus, Micrococcus, Corynebacterium,
and infection Propionibacterium (now called Cutibacterium),
Risk factors for CRPT complications (Table 2) Brevibacterium and Dermobacterium. Additionally,
and infection 67
include midline or mediolateral the Gram-negative Acinetobacter and a yeast
episiotomy68,69 and, in a small study only, (Malassezia) are also part of the normal

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community.76 Often these communities exist Table 2. Risk factors for CRPT
as biofilms. This complex flora is influenced complications64
by diverse factors, with commensals helping Modifiable risk factors Reference
to protect against potentially pathogenic
Episiotomy 67–69, 71–74
organisms.77 Studies of the skin microbiome
Third or fourth grade tears 71–74
indicate that the commensal bacteria play an
Assisted vaginal delivery 312, 67, 71–74
important role in modulating the host immune
Smoking 74
system.78 Staphylococcus aureus, for example, is
Repair by a midwife 74
carried by up to 30% of healthy individuals on
the skin without detriment. Coagulase-negative Experience of the practitioner 70

staphylococci (particularly Staphylococcus Chromic suture 74

epidermidis and Staphylococcus hominis) seem Catgut suture 70
to play an important role in suppressing BMI >35kg/m2 31
Staphylococcus aureus by producing antimicrobial Prolonged rupture of membranes 67, 70
peptides. One major inhabitant of the skin is Non modifiable risk factors
Corynebacterium, which although considered to be Maternal age (older age) 31
non-pathogenic, has been found increasingly in Meconium-stained fluid 71–73
chronic wounds.79 Birth weight (higher weight) 31
Primiparity 74
The diversity within the skin microbiome differs
between individuals.77 As an example, molecular
techniques used to compare the microbiome at
skin sites in women who were either obese or procedure. Findings suggested that obese women
non-obese, before and after caesarean delivery, were at higher risk of SSI due to their unusual skin
showed significant differences.80 Incision sites flora at the incision site before surgery, together
before surgery in women who were obese carried a with the carriage of vaginal flora to closed wound
higher bacterial load with lower diversity than in sites on obstetricians’ gloves.80
women who were not obese. Genera of anaerobic
bacteria such as Anaerococcus, Peptoniphilus, Natural microbial flora of the female
Finegoldia, Prevotella and Porphyromonas genital tract
were increased, while commensals such as The indigenous microbiota is a relatively complex,
Staphylococcus and Corynebacterium were reduced dynamic community comprising aerobic/facultative
in women who were obese. For women who species and strict anaerobes, and dominated by
were obese, antisepsis with chlorhexidine at the lactobacilli.81 Conventional culture determined
incision site reduced bacterial load to that of that genera present included Lactobacillus,
women who were not obese; however, biofilms Staphylococcus, Corynebacterium, Streptococcus,
were still detected in 75% of skin biopsies of Enterococcus, Candida albicans, Bifidobacterium,
women in the obese group. Vaginal load was
80
Gardnerella vaginalis, Cutibacterium, Gram-positive
similar in both groups of women. After caesarean anaerobic cocci, Bacteroides, Porphyromonas,
delivery, there was increased bacterial DNA Prevotella, Clostridium, Fusobacterium, Veillionella,
found on obstetricians’ gloves and at incision Ureaplasma and Mycoplasma.76 Additional colonising
sites following wound closure, which indicated bacteria are Gram-negative rods such as Escherichia
that sterility was not maintained throughout the coli, Klebsiella, Enterobacter and Proteus. Anaerobic

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bacteria significantly outnumber aerobic bacteria reproductive tract has revealed an entirely
in colonising the cervix of healthy women. 82
non-sterile environment with distinct microbial
Culture-independent investigation of vaginal flora communities in the cervical canal, perineal fluid,
in healthy women identified five distinct groups uterus and fallopian tubes that differed from
whose flora was dominated by either Lactobacillus that of the vagina.88 The placenta has also been
iners, L. crispatus, L. gasseri, L. jensenii or mainly shown to carry a distinct microbiome composed
strict anaerobes. For all groups, the production of of non-pathogenic commensals similar to that of
lactic acid was considered to be an important factor the human oral microbiome.89 Implications for
in protecting the vagina against infection.83 postpartum infections are not yet understood.

One commensal that has attracted much attention Common pathogens of the female
is Streptococcus agalactiae, which is a group B genital tract
haemolytic streptococcus (GBS). Colonisation by The skin and mucous membranes of the genital
this bacterium is a known risk factor for pregnant tract and abdomen provide a mechanical barrier
women. It was first identified as a human pathogen to the environment. However, breaches caused by
in 193884 and has been implicated in cases of traumatic injury (vaginal delivery) and elective
maternal and neonatal sepsis. Although there surgery (episiotomy or caesarean section) generate
are limited data on the global burden of GBS, 85,86
wounds that allow the ingress of microbial species
a clone carrying the resistance determinant for that can give rise to infection.
tetracycline has caused many fatalities.87
In wound infections associated with childbirth
Microbial species were traditionally thought the main endogenous reservoirs of infection are
to be confined to the lower genital tract, but the vagina and skin, and to a lesser extent, the
sampling at six sites throughout the female gastro-intestinal tract. The causative agents may
be part of the natural flora of the maternal host
(endogenous) or derived from other patients,
Fig 7. The skin has a diverse microbiota dominated by healthcare staff, relatives, medical equipment or
Gram-positive bacteria. Scanning electron micrograph of
Staphylococcus aureus. Image from [Link] other environmental surfaces (exogenous).81

Until the 21st century, investigations of microbial

flora were performed by culturing human
specimens to isolate and identify individual
species. These studies were limited by the culture
conditions used, and fastidious organisms are
likely to have been underestimated because of
their inability to grow on the media chosen and
their low population densities.78 More recently,
culture-independent molecular techniques relying
on gene cloning and sequencing have become
available and the presence of a much broader
range of species, some previously not described, in
human hosts has been demonstrated. Molecular
techniques also provide an accurate means to

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estimate bacterial numbers. Despite extensive shown to triple the risk of perineal infection.31
study, the complex interactions between hosts Microbes implicated in wound infection include
and invading microbes that result in infection are species of streptococci, staphylococci, Gram-
still not entirely understood. negative enteric bacteria and anaerobes, although
normal flora have also been recovered from wound
swabs.93 One case of toxic shock syndrome caused
Postpartum wound infections by methicillin-resistant Staphylococcus aureus
The epidemiology of postpartum wound infections (MRSA) in a perineal infection has been reported.94
is not easily collated. Signs and symptoms usually Further research is warranted particularly in the
present after discharge from hospital and the sphere of wound assessment.
patient may then report to a different healthcare
service. Infection associated with wounds during
childbirth can be divided into perineal/episiotomy Wound assessment
infections and surgical site infections following There are several frameworks for wound
caesarean section. A comprehensive study of assessment and wound bed preparation. These
postpartum infection conducted in Denmark include TIME (tissue, inflammation/infection,
included 32,468 births and the prevalence of moisture balance and wound edge),95–97 modified
wound infection was calculated as 5% after to TIMERS,98 to include regeneration of tissue
caesarean section and 0.08% for vaginal births, and social factors. Others include DOMINATE
more than 75% of which were recorded after (debridement, offloading, moisture, infection/
hospital discharge.90 inflammation, nutrition, arterial insufficiency,
technical advance and (o)edema)99 or Triangle of
Infections associated with perineal tears wound assessment,101 as well as wound assessment
and episiotomy tools (WAT).101 All are intended to help clinicians
Perineal infection in childbirth-related perineal to assess a wound and develop a care plan in a
trauma is associated with perineal pain, wound concise and systematic way. However, most WATs
dehiscence and/or purulent discharge.91 published to date have been developed for hard-
Information concerning postpartum infections to-heal wounds rather than perineal wounds and
following traumatic injury during vaginal birth in so the literature is limited.
published studies is limited. A systematic review
by Jones et al28 found that in 23 studies (11 cohort, The WUWHS position document100 indicates that
two case control and 10 reporting incidence), optimal wound management requires attention to
the reported incidence of CRPT wound infection three critical elements:
ranged from 0.1% to 23.6% and wound dehiscence
from 0.21% to 24.6%. Quality assessment of the • Determining aetiological factors, followed by
included studies exposed inadequacies in several interventions to correct or ameliorate those
methodological areas. Heterogeneity among the factors
studies was observed, particularly regarding perineal • Assessing systemic factors affecting wound
wound infection definition and confirmation, repair, with measures to optimise the repair
making effective synthesis of the data almost process
impossible.28 The prevalence of perineal infection • Assessing the wound, including the wound edge
following CRPT at operative vaginal birth in the and the peri-wound skin status, as a basis for
ANODE trial was >15%.92 Episiotomy has been topical therapies to promote healing.

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Greatrex-White and Moxey101 studied how well discharge, feeling unwell, pyrexia, wound
different wound assessment tools met the needs of dehiscence or abscess formation.104 REEDA scoring
nurses in carrying out general wound assessment proved valuable with students as a method of
and whether current tools were fit for purpose. increasing their observational skills for perineal
They showed that of 14 selected WATs, the Applied wound healing complications and assisting with
Wound Management (AWM) 102
and National reducing associated pain during the postnatal
Wound Assessment Form (NWAF)103 best met period. However, in another study, the REEDA
nurses’ needs in carrying out wound assessment. tool had poor inter-rater reliability on some
components and needed further enhancement.107
Assessment of perineal wounds This suggests that the REEDA scale may be helpful
Examining perineal wounds requires that the for an individual patient when used by one
woman adopt a position that facilitates inspection physician or midwife during follow-up of the
of the entire perineum. This will ensure the healing process, but care should be taken with the
efficient assessment of the wound and progress interpretation when comparing assessments of
to healing as well as early detection of signs of different observers.
delayed healing. At each postnatal contact, women
should be offered a thorough perineal assessment Despite this known limitation in its validity, in
if they have any concerns about their perineal the absence of any other scale, the REEDA has
wound, including perineal pain, discomfort been used to investigate interventions that aimed
or offensive odour. Any signs or symptoms to to assess perineal suture techniques108, perineal
suggest infection, inadequate repair or wound pain in the suture,109,110 postpartum perineal
dehiscence should be acted upon promptly care,109 the effect of laser irradiation on perineal
and appropriately. Specifically, for perineal
25
pain110 and wound healing with regard to tearing
wounds, two wound assessment tools have been of superficial perineal muscles112. However,
developed: the Perineal Assessment Tool (PAT) the systematic review by Jones et al28 of the
and the Redness, Oedema, Ecchymosis, Discharge, incidence of CRPT infection highlights the lack
Approximation (REEDA) scale (Table 3).104,105 of a standardised, validated assessment tool for
CRPT and a lack of consensus regarding definition
These scales use similar categories and descriptors of outcomes, with 71% of studies having no
to assess the same items. However, their main definition of infection.
difference is that the PAT operational settings
are less objective than the REEDA scale, and
therefore, the PAT has low reliability. The PAT The impact of wounds
scale 106
has also been used to assess problems on the patient
regarding incontinence-associated dermatitis Pain
rather than perineal wounds following childbirth. Little is mentioned to the expectant mother
regarding postnatal recovery and too many
The REEDA scale women who experience extensive injury are
The REEDA wound assessment scoring tool was ill prepared for the discomfort and effects that
designed to facilitate measurement of healing this pain has on their ability to cope with the
of an episiotomy using five components of the pressures of being a new mother.114 Everyday
healing process that may suggest infection, such activities are a challenge. Their ability to cope
as increase in pain, oedema, excessive/offensive with the day-to-day care of their baby often

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Table 3. Assessment categories, descriptors and score comprising the REEDA scale
Score Redness Oedema Ecchymosis Discharge Approximation
0 None None None None Closed
1 Mild Mild Mild Serum Skin separation 3mm
Less than 0.5cm from Less than 1cm from Less than 1cm from or less
each side of the wound each side of the wound each side of the wound
edges edges edges
2 Moderate Moderate 1cm to 2cm Moderate 1cm to 2cm Serosanguinous Skin and subcutaneous
0.5cm to 1cm from from each side of the from each side of the fat serparation
each side of the wound wound edges wound edges
edges
3 Severe Severe Severe Purulent Skin and subcutaneous
More than 1cm from More than 2cm from More than 2cm from fat and fascial layer
each side of the wound each side of the wound each side of the wound separation
edges edges edges
Total
Source: Davidson104

requires extended assistance from loved ones activities of daily living, shopping, visiting friends
and additional visits from midwives. It affects and attending new mothers’ groups. Women can
the ability to sit, not ideal when trying to feel extremely isolated during this time.117
establish breastfeeding. The mother, already
sleep deprived, will be in low spirits, and Granuloma and overgranulation tissue
the addition of pain and the possibility of after CRPT
incontinence contributes to the increased risk Prolonged inflammation can impair healing as
of postnatal depression. Postpartum depression a result of the accumulation of macrophages,
(PPD) affects approximately 10–20% of mothers, fibroblasts and collagen to create granuloma.118
making it the most common serious postpartum Granuloma is commonplace, whether due to
disorder.115 Unfortunately, the rate of diagnosis infection, inflammation around suture material
and treatment is low, due to a lack of recognition or possibly due to friction at, or close to, the
by the healthcare provider.116 perineum. The patient may experience an initial
improvement in perineal discomfort only to find
Long-term consequences that pain returns. This is a difficult problem to
Acute pain as a result of soft tissue trauma should manage. No guidelines exist for the management
resolve quickly with the correct treatment, of overgranulation of the perineum. The use of
management and support from healthcare silver impregnated applications is controversial due
providers. However, it is possible that pain to breast feeding and the possibility of breastmilk
returns in a different guise: from overgranulation being affected. The resumption of intercourse is
of tissue, scar pain or nerve pain. Delayed often delayed and may not be possible at all. The
recovery from childbirth is common in women reasons for this are likely to be multifactorial, but
who experience perineal wound and caesarean fear and the formation of tight, stiff scar tissue
section infection or dehiscence. Mobility may be are likely to be causes. The scar may benefit from
compromised, preventing women from resuming perineal massage to make it more malleable.

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Counselling regarding the whole event of of 6.9%) and 45/939 yielded positive culture
childbirth is useful for a couple. To debrief allows results. Ureaplasma urelyticum was isolated most
women to understand the process and why injuries frequently, with coagulase-negative staphylococci
occur, therefore it is imperative that women have and Enterococcus faecalis less frequently. Genital
knowledge of, and access to, this type of service. mycoplasmas were, therefore, most often isolated
Difficulty with sexual intercourse and dyspareunia from this cohort of patients.120 Pathogens also
may affect as many as 30% of all women 3 months associated with SSI after caesarean sections are
after the birth.25 In one study, dyspareunia was Staphylococcus epidermidis, Staphylococcus aureus, E.
reported by 44.7%, 43.4%, 28.1% and 23.4% of coli, Proteus mirabilis, group B streptococcus (GBS)
women at 3, 6 12 and 18 months postpartum, and anaerobes.121 A systematic review of SSIs
respectively.119
The second major consequence of globally examined the epidemiology of GBS and
birth trauma relates to the incisional, caesarean noted its involvement in a substantial proportion
section wound and the risk of subsequent wound of invasive SSI post-caesarean section.122 GBS is
complications, such as infection. considered to be a leading contributor to adverse
outcomes for both mothers and neonates.123

Complications associated
with the caesarean section Invasive infections affecting
incisional wound deep tissue and organ space
Surgical site infection (SSI) is defined as 'an Necrotising fasciitis
infection that occurs within 30 days of the Necrotising fasciitis is a potentially fatal, rapidly
operation and involves the skin and subcutaneous developing invasive infection that causes necrosis
tissue of the incision (superficial incisional) of subcutaneous tissue and fascia. It has been
and/or deep soft tissue (for example, fascia, reported as an infrequent complication following
muscle) of the incision (deep incisional) and/ caesarean delivery, with an incidence of 1.8%.22
or any part of the anatomy during an operation Type I necrotising fasciitis is characterised by a
(for example organ/space) that was opened polymicrobial infection of aerobic and anaerobic
or manipulated during an operation'.45 Since bacteria; type II is caused by a single pathogen.
caesarean section involves incision into the Synergistic combinations isolated from infected
abdomen and uterus, it is classified as clean- patients in one study included Staphylococcus aureus,
contaminated surgery.119 Although much has been Enterobacter agglomerans, Acinetobacter baumannii
published on the microbial species causing SSIs and two strains of Enterobacter cloacae.125 In
in general, there is less information concerning another study, Staphylococcus aureus, streptococci,
pathogens implicated in caesarean section enterococci, E. coli, Bacteroides fragilis and clostridia
wound infections. For example, in one study, were implicated.126 Pathogens linked to type II
939 wounds in post-caesarean patients were were group A streptococci or MRSA.127 Rapid
followed prospectively and investigated if signs diagnosis and intervention with sharp debridement
of infection developed.120 Wound morbidity was and broad-spectrum antibiotics are required for
detected in 65/939 wounds (cumulative incidence successful outcomes with this infection.125

Postpar tum depression (PPD) affects approximately 10–20% of mothers, making it the most common serious
postpar tum disorder.113

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Endometritis General treatment
Originally known as puerperal fever, endometritis principles and clinical
is an infection of the upper genital tract, management options
including the endometrium, myometrium and Perineal injuries
surrounding tissue. It is caused by bacteria • Assess the wound for signs of infection and take
translocated from the vagina or abdominal skin a wound swab for culture and sensitivity if an
into the uterus. It can occur following vaginal infection is suspected. Guidelines are available.136
delivery but is at least five times more likely to • If signs of infection are present, commence
arise following caesarean section and affects a broad-spectrum antibiotic (co-amoxiclav)
between 2% and 16% of women. 128
The first with the aim of reducing the risk of wound
pathogen implicated in puerperal fever was dehiscence.
Streptococcus pyogenes.129 In 1933, streptococci • Clean and debride the wound using sterile water
were divided into groups on the basis of the or isotonic saline, taking time and great care not
components in their cell walls and Streptococcus to inflict further injury and reduce discomfort.
pyogenes was allocated to group A and is known as If the woman is breastfeeding, silver-based
a group A streptococcus, or GAS.130 products are contra-indicated.
• Continue to review patients on a regular basis to
Before the antibiotic era, GAS were associated with ensure healing is progressing or to identify those
significant morbidity and mortality in puerperal who require expert management.
fever, but incidence reduced between 1940s and As perineal wounds may overgranulate due to
1980s. Since the 1990s, sporadic cases of invasive friction or infection,137 there will be an absence
GAS infection (iGAS) have occurred. In 2010, iGAS of scab formation. The wound, therefore, remains
became a notifiable disease in England and Wales. moist, and, due to the site, typically difficult to
GAS was recognised as a leading cause of maternal apply a dressing. The community physician should
sepsis,131 with 61% and 1% of cases associated with be contacted with a request for topical preparations
the genital tract and caesarean section wound site, (e.g. silver-containing agents). Such topical
respectively.131 Polymicrobial infections involving treatments can be commenced in the outpatient
aerobes, anaerobes and genital mycoplasmas were setting. In contrast, excessive scar-tissue formation
implicated in endometritis, with Gram-negative or poor alignment of tissues in the initial repair
bacteria found in 10-20% of cases following may require additional reconstructive surgery, for
caesarean section.132 E. coli was the most frequent example, perineal refashioning, perineorrhaphy
isolate followed by Klebsiella pneumoniae, Proteus (suturing of the perineum) or a modified Fenton’s
mirabilis and Enterobacter spp.132 In another study, procedure to widen the introitus if there is
coliforms, streptococci, anaerobic cocci, bacteroids excessive scarring.138
and Ureaplasma urealyticum were associated with
post-caesarean section endometritis.133 In Finland, Caesarean section wounds
vaginal colonisation by group C or G streptococcus Dressings and advanced wound
was associated with endometritis. 134
Until recently technologies
these bacteria were not considered to be pathogenic. There are so many dressings available on the
One case of necrotising endomyometritis caused market that the choice may be overwhelming
by multidrug-resistant E. coli was been reported, to the novice and expert alike. Table 4 provides
highlighting the problems of the continued a summary of the characteristics and dressing
emergence of antibiotic-resistant pathogens.135 properties of most categories available at the time

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of writing. The primary principles for dressing use caesarean delivery could not be demonstrated in
in the management of birth wounds are to: this study. Therefore, the effects of binders on
wound healing after caesarean section is unclear.
• Protect the wound site
• Prevent contamination of the wound site The use of wound care dressings and the
• Create an environment that is conducive to scientific and clinical evidence base
wound healing While there are a large number of wound care
• Promote comfort for the postpartum mother dressings available, it is important to consider the
evidence base for their indicated use. Although
When a complication, such as infection or there is limited evidence on the use of modern
dehiscence, occurs, the use of dressings plays a interactive dressings for preventing surgical site
different role, and can be used to manage exudate, infections,142 the National Institute for Health and
infection, generate tissue granulation or create Care Excellence (NICE) in the UK recommends
a moist wound healing environment. Correct covering surgical incisions with an appropriate
assessment and diagnosis of the wound healing interactive dressing at the end of the procedure.58
stage is key to ensure that the most appropriate
dressing is used to facilitate optimum healing. The World Health Organization guidelines for
A high standard of documentation, including a the prevention of surgical site infection also
wound care plan that is designed for the patient, recommends 'not using any type of advanced
should be used and shared among all healthcare dressing over a standard dressing on primarily
providers to ensure continuity of care.59 closed surgical wounds for the purpose of
preventing SSI'.58 This recommendation is based
Wound aids in the form of an abdominal binder on the absence of high-quality evidence to
(or compression belt) to encircle the abdomen, support this indication. A meta-analysis of 16
providing support to the incision, may be of trials yielded no differences between different
value after caesarean section, although there wound dressings and prevention of SSI.143 Another
is a paucity of evidence. Elastic binders are systematic review investigated the timing of
considered to speed recovery and to promote postoperative dressing removal and revealed no
wound healing. A systematic review of their statistically significant difference between early
use after abdominal surgery revealed a (non- versus delayed dressing removal in the prevention
significant) tendency to reduce seroma formation of SSI.144 Whereas, the findings of a randomised
after laparoscopic ventral herniotomy and a controlled trial comparing early and late dressing
non-significant reduction in pain.139 The quality removal following caesarean section, revealed
of evidence of the reviewed papers was rated as that women were pleased and satisfied with
poor. Gustafson et al140 reported significantly early dressing removal.145 The study also revealed
lower average postoperative pain scores when that more complications were experienced in
compared to a control group. However, in a the early removal group compared with the
randomised controlled trial, Chankhunaphas standard removal time group, although this was
and Charoenkwan141 showed that there was not statistically significant.145 Stanirowski et
no significant between-group difference in al146 revealed a reduction in SSI rates following
quality-of-life dimensions, overall health status caesarean section when using a dialkylcarbomyl
and postoperative complications. The positive chloride (DACC) impregnated dressing compared
effects of elastic abdominal binder use following with controls. A two‐arm, parallel‐group, pilot

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feasibility randomised controlled trial in a and urinary tract infections following childbirth
vascular cohort, yielded similar findings in the contribute to maternal morbidity and demand
prevention of SSI using DACC impregnated effective antimicrobial treatment. Antibiotics have
dressings compared to controls.147 been used in the successful treatment of infections
during the past 70 years, but the widespread
While there is a growing body of evidence to use and overuse of antibiotics has allowed the
address key questions about prevention and emergence of resistant strains of microbial species.
management of SSI, dressing use should be based Furthermore, organisms may possess resistance
on current evidence and guidelines,58,59,148 local to antiseptics, to multiple antibiotics or exhibit
policies and clinical judgement, which may be resistance to both antibiotics and antiseptics.
guided by Table 4. Now antimicrobial resistance (AMR) has become
a global problem155 that requires global action.156
At the time of writing, there is considerable This threat to effective management of wound
discussion about the efficacy of negative pressure infection has been noted157 and the need to use
wound therapy (NPWT) for the prevention of SSI antibiotics judiciously has been recognised.158–160
after caesarean section. Several systematic reviews With limited hope of finding new antibiotics, it is
provide conflicting evidence for the effectiveness important to increase efforts to prevent infections
of this advanced dressing as prophylaxis for and to conserve the therapeutic value of existing
prevention of SSI.152–154 Moreover, the World antimicrobial interventions as indiscriminate use
Health Organization guidelines clearly state that, facilitates the continued emergence of resistant
while this type of dressing may be used, there is strains. Alternative approaches to wound care are
low-grade, poor-quality evidence to demonstrate being explored, for example the role of medicinal
effectiveness of SSI prevention.58 Consequently, honey in wound management.
there remains uncertainty with regard to the use
of NPWT for prophylaxis of SSI in the obstetric The role of honey in wound care
population. More evidence from systematic review Honey is an ancient wound remedy that has
or meta-analysis of all relevant RCTs (level one been re-introduced into modern wound care.
research) is required to investigate the benefits, There is some evidence that it might be useful in
both health-related and economic, of NPWT and managing birth-related wounds, but larger studies
other advanced dressing use in obstetrics and will be needed to inform current practice. Lower
maternity care. rates of each of wound infection161,162 and wound
dehiscence158 and faster healing rates163,164 have
been observed in women whose caesarean section
Topical issues and incision sites were treated with honey compared
controversies to conventional interventions. Faster wound
Today, clinical practice is largely based on healing for episiotomies were reported with honey
objective evidence. Normally well designed, compared to placebo, but there was no reduction
appropriately powered, double blinded, in pain.165 An adhesion model in rats has shown
randomised controlled clinical trials provide that honey significantly reduced the severity of
data that contribute to systematic reviews and postoperative peritoneal adhesions compared to
meta-analysis, from which clinical guidelines isotonic saline.166 Further studies are required to
are constructed and informed decisions made determine the full clinical and cost-efficacy of
by practitioners. Wound infection, endometritis honey in birth wound complications. The more

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conventional approach to treating wound infections tears to the NHS (England) at £10.7 million and
is the use of antibiotic medication; however, there £1.5 million, respectively. Despite initiatives to
is now global concern about the development of improve maternity care, the incidence of severe
resistance to antibiotics, reducig their efficacy, perineal lacerations leading to OASI is increasing.168
which carries the risk of significant morbidity.156 Improvements in maternity care to enhance the
Failure to treat and manage patients with wounds wellbeing and safety of women is recognised as
will have a significant bearing on health system an issue of national concern,169 particularly when,
resources and ultimately the economy. for women who had a third- or fourth-degree tear
during their first birth, recurrence of the injury was
7.2% compared with 1.3% for women without a
The impact of birth-related tear.170 The rise in the number of these CRPT events
wounds on the economy may lead to other related, longer-term conditions
It is widely recognised that after caesarean section that further impact on the physical and emotional
the risk of SSI is high, especially in women with wellbeing of women who have lingering obstetric
obesity.64 While the majority of surgical wounds problems that require further healthcare services
heal by primary intention within 7 days, a over periods of time lasting from 4 to 8 years.171
proportion do not. Incised wounds that are slow to
heal, rupture or become infected require ongoing Within the wound care community, there is
treatment, inflating the initial healthcare costs. recognition of the escalating costs of unhealed
Wloch et al56 estimated the healthcare costs for surgical and hard-to-heal wounds. The cost of
SSI after caesarean section in England, taking into the estimated 2.2 million wounds in England is
account that while the majority of infections are £4.5–5.1 billion, with predicted acute and chronic
superficial (88%), a proportion are severe and in wound prevalence growing year on year at 9%
some cases fatal. Cost-analysis data for 2010–2011 and 12%, respectively.172 Finding new ways to
from one hospital that carried out 800 caesarean achieve best practice in assessment, diagnosis
sections had an estimated infection risk of 9.6%. and rational management strategies for patients
Costs of SSI were an estimated £18,914 (95% CI will reduce costs. Here, the use of antibiotics in
11,521–29,499), £5370 (28%) of which were for childbirth, especially antibiotic prophylaxis is
community care. Extrapolated nationally and now under intense scrutiny.
with inflation to 2019 prices, this equates to an
estimated cost of £5 million for all caesarean The use of antimicrobials after childbirth
sections performed in England for period 2018– Antimicrobial agents are routinely prescribed
2019.56,57 prophylactically during childbirth, particularly
for caesarean section. Robust reviews of the
These data, extrapolated globally and updated to clinical evidence of the efficacy of antimicrobial
current treatment costs represent a significant drain prophylaxis for women undergoing vaginal
on healthcare resources for what is an avoidable delivery (Table 5) or caesarean section (Table 6)
birth-related complication. have been published and have been incorporated
into various international and national guidelines.
Orlovic and colleagues167 used hospital episode Currently WHO guidelines recommend
statistics (HES) for 2010–2011 and 2013–2014 routine antibiotic prophylaxis for elective and
and estimated the overall economic burden emergency caesarean section, third- and fourth-
of inpatient third- and fourth-degree obstetric degree perineal tears, but not for episiotomy,

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 Table 4. Wound dressings for the management of surgical wounds (after NICE145 and WHO56)
Dressing Dressing characteristics Wound characteristics*/ Primary clinical indications Phase of
category healing intention management
Advanced (interactive)
Vapour-permeable Permeable to water vapour and oxygen, but not to water or Superficial Facilitate optimum healing environment (moist Intra-operative (in
films microorganisms. They are normally transparent Minimal exudate wound healing) and provide a barrier to theatre)
Primary intention bacteria/protect incision site Post-operative
Community/home-
care settings
Hydrocolloid Vary significantly in their composition and physical properties. Superficial Facilitate wound hydration and optimum Post-operative
dressings In general, they consist of a self-adhesive gel-forming mass Low exudate wound healing environment. (usually)
applied to a carrier, such as a thin polyurethane film or a foam Primary and secondary intention Promote autolytic debridement and Community/home-
sheet. They contain colloidal particles, such as quar, karaya, proteolytic digestion care settings
gelatic, sodium carboxymethylcellulose, gelatin and pectin, in an
adhesive mass usually made of polyisobutylene. In their intact
state, hydrocolloids are virtually impermeable to water vapour.
By trapping wound exudates, hydrocolloids create a moist
environment that softens and lifts dry eschars. They also favour
granulation tissue formation and re‑epithelialisation
Hydrogels Consist of 80–90% water and insoluble cross-linked polymers, Superficial or deep Rehydration of tissues and some absorption of Intra-operative
or fibrous such as polyethyleneoxide, polyvinyl pyrollidone, acrylamide or Low–moderate exudate exudate. (occasionally)

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hydrocolloid carboxymethylcellulose, with hydrophilic sites that interact with Secondary intention Facilitate optimum healing environment Post-operative
dressing aqueous solutions, absorbing and retaining significant volumes and protect incision site. Some absorbency Community/home-
of water potential. care settings
Polyurethane Consist of two layers: a polyurethane gel matrix and a Superficial or deep Indicated for clean, granulating/sloughy or Intra-operative
matrix hydrocolloid waterproof polyurethane top film designed to act as a bacterial Low–moderate necrotic wounds. Post-operative
dressing barrier exudate Limited absorbency capacity: the amount of Community/home-
Primary and secondary intention exudate that a hydrocolloid dressing can absorb care settings
is dependent on the MVTR of the backing layer
Alginates Manufactured from salts of alginic acid (source: brown seaweed). Superficial or deep Absorbency of exudate; maintains a moist Intra-operative
On contact with wound exudate, ionic exchange occurs in the Low–moderate–high exudate wound surface and promotes the removal of (occasionally)
alginate and a hydrophilic gel forms. Secondary intention cellular debris/slough from the wound surface Post-operative
The nature of this exchange is dependent on the amount of (bed) Community/home-
guluronic (g) and mannuronic acid (m) used in manufacture. The care settings
amount of g and m acid in the dressing also determines its ability
to absorb exudate, retain its shape and how it will be removed
from the wound. Available in sheet/rope/cavity filler form

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 Polyurethane foams Made of polyurethane and available in a variety of forms: simple Superficial when used as a Absorbency of exudate; maintains the optimum Intra-operative

S24
foam sheets, film-backed foam sheets, polyurethane foam gels primary dressing or deep when healing environment and can minimise the risk Post-operative
(hydro polymer) and cavity fillers (tube dressings). One variety used as a secondary dressing of trauma at the wound surface at the time Community/home-
has additional additives, e.g. glycerine and a surfactant Low–moderate–high exudate of dressing change (dependent on product care settings
Secondary intention (usually) chosen)
Bacteria- and fungi-binding dressings
Dialkylcarbamoyl Facilitate the binding of micro-organisms to the dressing as a Superficial–deep Can be used both for infection prevention as Intra-operative
chloride (DACC) result of the specific surface characteristics using the principles of Low–high exudate well as for treating already-infected surgical Post-operative
coated dressings hydrophobic interaction. Primary and secondary intention wounds. No known mechanism of resistance Community/home-
Common wound microorganisms, including MRSA, bind to development. Suitable for prolonged duration care settings
the dressing surface from the wound bed and are removed at of treatment
dressing change
Antimicrobial Should not be used routinely for prophylaxis (i.e. to prevent infection). However, some antimicrobial products may contribute to the reduction of SSI risk in some surgical
dressings patients. Clinicians should make their decision to use any antimicrobial product prophylactically in view of their knowledge of the properties of the product being considered;
the evidence available to support its proposed use, and their own previous experience with the product/dressing
Polyhexametylene Common antiseptic used in a variety of products, including Superficial or deep Wound cleansing; wound bed preparation— Post-operative
biguanide (PHMB) wound care dressings and wound cleansing solutions, Moderate–high exudate the stimulation and influence of specific (usually)
dressing perioperative cleansing products, contact lens cleansers and Secondary intention cells involved with the immune system and Community/home-
swimming pool cleaners. the management of wound infection in care settings
conjunction with appropriate systemic therapy.
Silver-impregnated Silver provides extensive coverage against bacteria, fungi and Superficial or deep Wound cleansing; wound bed preparation— Post-operative
dressing viruses, including nosocomial pathogens, MRSA and VRE, Moderate–high exudate the stimulation and influence of specific cells (usually)
making it a valuable adjunct in the prevention and treatment of Secondary intention involved with the immune system and the Community/home-
infection. Silver has both bactericidal effects via oxidation of the management of wound infection in conjunction care settings
cell membrane and bacteriostatic effects by inhibiting bacterial with appropriate systemic therapy
replication through damage to DNA
Povidone iodine Iodine is an antiseptic that targets a broad spectrum of bacteria Superficial wounds Iodine is an oxidising agent and its bactericidal Post-operative
impregnated and other pathogens. It has been used successfully, without Minimal exudate activity is inorganic with essentially no
dressings complications, for the management of many chronic wounds; Secondary intention development of resistance by microorganisms
however, there is currently little evidence to support its use for
the prevention and long-term management of SSI
Advanced (active)
NPWT dressings Primarily designed to prevent exudate collection while Deep These dressings increase oxygen tension Intra-operative
simultaneously preventing desiccation of the wound Low–moderate–high exudate in the wound, improve blood flow to the Post-operative
Secondary intention wound bed, decrease bacterial count, increase Community/home-
granulation formation and minimise shear care settings
forces on the wound surface

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 Basic wound contact layers
Absorbent dressing These are non-occlusive permeable dressings that allow Superficial Additional absorbency of exudate over Not generally
pads moisture to be absorbed and to evaporate into the atmosphere. Low exudate another primary dressing or a low adherent recommended
Many comprise a soft viscose, polyester-bonded pad that may or Primary or secondary intention wound contact layer (see below). in theatre or the
may not have an external polyethylene contact layer. (when used as a secondary immediate post-
‘Superabsorbers’ consist of absorbent polymers (some of which dressing) operative phase.
expand on absorption of fluid); however, this is a comparative Superficial May be used as a
not absolute term Low–moderate exudate secondary dressing
Secondary intention (occasionally)
(usually, when used as a
secondary dressing)
Low-adherent Consist mainly of a fine mesh gauze impregnated with Superficial Widely used, primarily as interface layers Intra-operative
wound contact moisturising, antibacterial or bactericidal compounds. Either Low exudate between the wound surface and a secondary (occasionally)
layers (traditional) non-medicated (e.g. paraffin gauze dressing) or medicated (e.g. Primary intention (usually) absorbent dressing. Usually made of cotton Post-operative
containing povidone iodine or chlorhexidine). As the dressing gauze to prevent adherence to the wound Community/home-
dries, fibrin from the wound bed causes temporary bonding of surface and avoid trauma on removal care settings
the dressing to the wound, permitting healing beneath it
Low-adherent Superficial but can be used to line Minimise risk of trauma at wound surface Intra-operative
silicone wound a deep wound, as in combination and patients' pain experience during dressing (occasionally)
contact layers with NPWT changes Post-operative
Low exudate (usually) when Community/home-
dressing used for its primary care settings

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clinical indication
Primary intention (usually), can
be secondary when used in
combination with NPWT
*Exudate is a generic term used to identify liquid produced from wounds.146,147 Bates-Jensen148 attempted to qualify the levels of exudate in relation to the terms often used by clinicians to describe the same
Low (minimal or small) exudate: wound tissues wet, moisture evenly distributed in wound, exudate affects 25% of dressing; moderate exudate: wound tissues saturated, drainage may or may not be evenly distributed in wound, exudate
involves 25–75% of dressing; high (or large) exudate: wound tissues bathed in fluid, drainage freely expressed, may or may not be evenly distributed in wound, exudate involves 75% of dressing
MRSA: methicillin-resistant Staphylococcus aureus; MVTR: moisture vapour transfer rate; NPWT: negative-pressure wound therapy; VRE: vancomycin-resistant enterococci
Reprinted with kind permission from Stryja et al57.

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uncomplicated vaginal birth or operative vaginal emergence of resistance to chlorhexidine,176,177
birth. Antiseptics are recommended for skin povidone iodine may be preferred.
preparation prior to incision at caesarean section
and povidone iodine is recommended for vaginal With the emerging threat of antimicrobial
cleansing. Chlorhexidine is not recommended for resistance and the unlikely discovery of
vaginal cleansing. 173
new antibiotics, existing infection control
precautions such as hygiene and cleaning must
Antimicrobials associated with be emphasised. It is better to prevent an infection
vaginal delivery than to treat one. One simple measure may be
Routine antibiotic prophylaxis to prevent for obstetricians to change gloves after caesarean
infection after operative vaginal delivery is delivery but before suturing to minimise
not recommended at present.173 A multicentre translocation of microbial flora from the vagina
randomised controlled trial, ANODE, on to the incision site.80 Alternative means of
prophylactic antibiotics in the prevention preventing infection should be sought, including
of infection after operative vaginal delivery, the possibility of vaccinating women against GBS
reported the benefit of a single intravenous dose in the late second or early third trimester has
of amoxicillin and clavulanic acid in preventing been considered.178
postpartum infection. 92
The study was conducted
at 27 obstetric units in the UK, and women were Perioperative antibiotic use for
randomly assigned to receive either amoxicillin caesarean section
and clavulanic acid (number of women=1719) Systematic reviews of antibiotic prophylaxis
or placebo (number of women=1798) following for caesarean section (Table 6) began during
operative vaginal birth at 36 weeks' gestation the mid 1990s. For recently updated systematic
or longer. Confirmed or suspected infection reviews, clinical evidence has been collated from
was significantly lower in women receiving studies ranging from 1968 to 2017, many of
amoxicillin and clavulanic acid compared with which were published in the 1980s. Generally,
those in the placebo group, indicating a benefit the quality of the evidence has been low to
for a single intravenous dose of amoxicillin very low, or of insufficient quantity. The most
and clavulanic acid and a potential need for reliable recommendation is that prophylactic
revision of the WHO guidelines. 92
The need antibiotics should be administered intravenously
for further research has been documented.174 before caesarean section incision.184 Despite
If the guidelines were changed to recommend guidelines endorsing the prophylactic antibiotic
routine prophylaxis following operative vaginal use for women undergoing caesarean section,
delivery, as in the ANODE trial, it would increase implementation has not been uniform.182
the burden of antibiotic use initially, but the
potential benefit could be the prevention of At the time of writing, there is evidence to
432,000 infections globally every year.175 Further suggest that there is no significant difference
research is needed to determine whether oral between the different classes of antibiotics
antibiotic prophylaxis would be as effective as a used prophylactically before caesarean section.
single intravenous dose. However, only immediate postoperative infections
have been researched and data relating to late
Clinical evidence of the efficacy of antiseptics during infections (up to 30 days postpartum) are not
childbirth is limited (see Tables 5 and 6). With the available.183 Cephalosporins and penicillins have

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Table 5. Summary of Cochrane reviews concerning prophylaxis as a means
to prevent maternal infection after vaginal birth
Intervention Evidence Number Risk Quality of Conclusions Ref
search of studies of bias evidence
(participants) (GRADE)
Antibiotic Aug 2014 1 (147) Low Moderate Antibiotic prophylaxis seems to 179
prophylaxis for prevent wound disruption and
3rd and 4th purulent discharge but evidence
degree perineal is limited to one small trial with
tears during high loss to follow-up
vaginal birth
Antibiotic July 2017 1 (73) High Very low Insufficient evidence to assess 180
prophylaxis for the clinical benefits or harms of
episiotomy repair routine antibiotic prophylaxis
following vaginal for episiotomy repair following
birth normal birth
Antibiotic March 2020 2 (3813) Unclear Low Further research is needed 174
prophylaxis for to decide whether antibiotic
operative vaginal prophylaxis after operative
delivery vaginal delivery is useful in
preventing postpartum maternal
morbidity
Antibiotic August 2017 3 (1779) High Low to very Well designed and high powered 181
prophylaxis for low studies are needed to evaluate
normal vaginal the effects of routine antibiotic
delivery prophylaxis in preventing
maternal morbidity after normal
vaginal delivery

mostly been used,183 but macrolides are required A review of antimicrobial prophylaxis for
for women with penicillin allergy. A role for caesarean section in China demonstrated that
their use in preventing wound infection and five different classes of antibiotic were being
endometritis in caesarean deliveries has been used, and that between four and nine different
suggested.188 agents were prescribed to each woman.190 In light
of antimicrobial resistance and the need to use
Concern over the use of broad-spectrum antibiotics conservatively, this is a concern.
antibiotics for preventing postoperative surgical
site infections following caesarean section has The midwife is key to education and the giving of
been raised in a study comparing the efficacy information to women both before and after the
of ampicillin to ceftriaxone.189 Incidence of SSI birth with respect to any drugs administered, as
for women treated prophylactically with either well as maternal care, treatment and surgery.
antibiotic did not differ and the authors argued
that the cheaper alternative (ampicillin) should
be favoured. Interestingly, antibiotic resistant The role of the midwife
bacteria were recovered from some infected Many midwives do not receive any formal
patients’ wounds.189 training on the assessment of perineal wounds

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Table 6. Summary of Cochrane reviews concerning antibiotic prophylaxis as a
means to prevent maternal infection after caesarean section (CS)
Intervention Date Number Risk Quality of Conclusions Ref
of of studies of evidence
search (participants) bias (GRADE)
Routine or no antibiotic July 2014 95 (>15,000) Unclear Moderate Routine antibiotic prophylaxis to all 182
prophylaxis for women undergoing CS recommended to
preventing infection prevent infection
after CS
Different classes of Sept 31 (7697) Low or Low Cephalosporins and penicillins have similar 183
antibiotic given to 2014 very efficacy at CS in preventing immediate
women routinely for low postoperative infections. Data for late
preventing infection at CS infections (up to 30 days) is not available
Timing of intravenous March 10 (5041) Low High Preoperative intravenous antibiotics decrease 184
prophylactic antibiotics 2014 risk of infectious morbidity compared to
for preventing administration after cord clamp
postpartum infectious
morbidity in women
undergoing CS
Routes of administering January 10 (1354) Unclear Low to very No clear difference between irrigation 182
antibiotics for preventing 2016 or high low and intravenous antibiotic prophylaxis in
infection after CS reducing the risk of endometritis after CS
Skin preparation for Nov 11 (6237) Low Low or very Insufficient evidence to fully evaluate different 185
preventing infection 2017 low agents and methods; unclear what sort of skin
following CS preparation most effective at preventing post-
operative surgical site infection
Vaginal preparation with July 2017 11 (3403) Low Moderate Vaginal preparation with antiseptics 187
antiseptics before CS for (povidone iodine or chlorhexidine) before
preventing postoperative CS reduced the risk of endometritis and
infections post-operative wound infection

and the actions to be taken if infection or a or in pain for days while a plan of care is
wound breakdown is suspected. The NICE formulated with the general practitioner (GP) or
postnatal care guidance148 advises that ‘signs and the attending obstetrician.
symptoms of infection, inadequate repair, wound
breakdown or non-healing should be evaluated Midwifery staff must be appropriately trained to
(urgent action)’. However, there is significant identify and refer women who have suspected
variation in practice on how this referral process perineal wound complications and/or infection
is perceived. Women can often be uncomfortable to allow direct and prompt access to appropriate
services. A streamlined referral system with direct
access into a women's health physiotherapy
With continuing emergence of antimicrobial resistance (WHP) service, that is equipped to offer women
and the unlikely discovery of new antibiotics, existing immediate specialist care at the first suspicion of
infection control precautions such as hygiene and wound breakdown or infection, helps to provide
cleaning must be emphasised.
personalised care and the rehabilitation necessary
to restore function for women who sustain perineal

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trauma at birth. WHP services liaise with the Going home
appropriate multidisciplinary team if needed to Women are usually discharged home from
ensure best possible recovery. hospital within 24 hours of the birth. Because
routine community visits may not occur,
Antenatal education information for women on wound healing
Midwives take a leading role in providing processes, how to care for the perineal wound
information and educating women during the and signs and symptoms of wound infection is
antenatal and immediate postnatal period on the especially important.193
prevention of perineal trauma and the care of
perineal wounds. For women to care for themselves effectively,
they need to understand the basic physiology
Antenatal care guidelines148 recommend that and anatomy of the pelvic region. Educational
women are offered advice on pelvic floor programmes are required to teach women about
exercises from the start of pregnancy. There is the physiological changes that occur during
no standardised method for teaching pelvic floor pregnancy, the impact that birth may have on the
exercises within maternity services. Women who pelvic floor and perineal body, and to understand
can attend physiotherapy services have access to how to care for these areas as a part of normal or
specialised care, but access is not universal. Many routine care. Women need a clear understanding
women have no access to services that help them of what pelvic floor exercises are and they
to prepare physically for the birth by learning should be confident to undertake such exercises
how to correctly engage the pelvic floor and core during and after pregnancy. Antenatal exercise
muscles during pregnancy, labour and birth. NICE programmes that focus on pelvic floor health are
antenatal care guidelines148 recommend that all recommended as a routine part of antenatal care
women are offered information on ‘postnatal to women.148,194
self-care’ at 36 weeks, but no further information
is offered. Educating women in personalised care
It is likely that following hospital discharge, advice to
Postnatal education women with caesarean section, especially those going
While there is a guideline and an accepted home shortly after surgery, will be provided with
pathway of care with routine follow-up after post-delivery advice. Some examples of frequently
OASI there is no pathway for other CRPT.30 No asked questions (FAQs) are provided in Appendix 1.
Cochrane reviews relate to care after CRPT. The
NICE guidance on postnatal care up to 8 weeks On discharge, women should be advised to examine
after birth 191
recognises the importance of their perineum to check for signs of infection or
evaluation of CRPT with the recommendation dehiscence, and be encouraged to continue pelvic
'signs and symptoms of infection, inadequate floor muscle training (PFMT). During the first days,
repair, wound breakdown or non-healing should gentle muscle contraction followed by complete
be evaluated'. WHO guidance also recommends
assessment of perineal healing192 but neither
Midwifery staff are to be appropriately trained to identify
guideline has evidence to inform how this should and refer women that present with signs and symptoms
be done, or how women with complications of having a perineal wound breakdown or infection.
should be cared for. Access to services in a timely manner is essential.

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relaxation, supports revascularisation and enhances clean the injured area.
healing. Once a woman feels more comfortable, • Allow air to get to the wound.
active PFMT will improve pelvic floor function.195 • Use maternity pads only (no plastic backed
pads) until the wound has closed. Plastic-backed
Signs and symptoms of perineal wound infection pads cause sweating, which can add to the
are an increase in pain, oedema, abscess formation possibility of infection.
cellulitis, excessive or offensive discharge, feeling • When passing urine or opening the bowels
generally unwell, pyrexia and wound dehiscence. women should always wash with water. This
helps to remove any urine or soiling that might
In the case of possible perineal dehiscence or have remained on the skin. Tepid water in a
infection the following should be considered: jug poured with the passing of urine will help
reduce stinging.
• Is the perineum bruised? Note that • When opening the bowels, support the
discolouration may take a few hours to become perineum with a pad of tissue paper or a warm
apparent. flannel held over the wound, relaxing onto the
• Is there excessive swelling? Oedema may be tissue paper without bearing down.
apparent in the labia but is not often observed • The use of appropriate analgesia should be
in the perineum. prescribed immediately to enable the women to
• Is there pain on palpation around the tissues mobilise and look after her baby.198,199
surrounding the wound? Is there tension • The use of a stool softener is useful to prevent
on palpation in these tissues? Tension often the occurrence of hard dry stools building up
indicates extensive bruising with possible in the pelvic cavity, further adding to pain and
haematoma. By using a visual analogue scale, tension of the perineum.
it is possible to determine the level of pain • Regular periods of rest should be encouraged
that the women is experiencing. Is there an to allow the injured muscles of the pelvic
increase in perineal pain? Note perineal pain floor to recover and reduce perineal oedema,
is very intensive during firsts days postpartum, particularly in the first 48 hours. Avoid
however it should decrease over the fifth day activities that increase intra-abdominal pressure
postpartum.196 for 6–12 weeks after the birth.
• Introduce pelvic floor muscle contractions at
regular intervals throughout the day in order
The following information is an example of ‘take to improve circulation and aid muscle recovery
home’ advice for women: and prevent muscle wastage.195
• Good nutrition is essential in order to promote
• Keep perineal wounds as clean as possible. speedy healing, healthy scar tissue and a normal
• Shower daily and, after going to the toilet, bowel habit. Encourage a healthy balanced
dry, using paper towels or a clean towel, diet, high-fibre food and drinking 1.5–2 litres of
from front to back (i.e. ureter to anal area), is water, especially if laxative or iron therapy has
very important. been prescribed.
• Always maintain good hand hygiene. Always
wash hands before and after touching the Women should also be aware of the signs and
injured perineum. symptoms relating to infection. If suspected,
• No soaps or body washes should be used to women should be encouraged to make contact

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with their designated healthcare professional During a difficult induced labour, I suffered an
in the event of wound odour, increased pain, episiotomy and second-degree vaginal tear. I had a
swelling, feeling unwell or rise in temperature.191 number of stitches, developed a large haematoma
and the wound became infected. In the days
Maternal mental health following the birth of my first child, the prescribed
The impact of perineal trauma on maternal pain relief and exhilaration of a healthy baby
physical and mental health must not be seemed to mask the severity of the injuries I had
overlooked, the physical and psychological sustained during labour. As a first-time mother I
trauma that women experience following birth had nothing to compare my experience to and
can affect women for many years. In some cases, understood my pain to be a standard consequence
perineal trauma can lead to long-term pelvic floor of giving birth. As a result, when initially
dysfunction, sexual dysfunctional that impacts questioned by a physiotherapist in the recovery
on a woman's self-esteem, and can even lead to ward, I underplayed the pain and discomfort I was
relationship breakdown. feeling and inadvertently sidestepped the referral
I needed. Thankfully the community midwife
Women have reported feeling unable to bond recognised my need for follow-up treatment and
with their baby due to the pain and discomfort I was referred to the physiotherapist team 7 days
they experienced in the weeks and months after giving birth.
following the birth, unable to breastfeed due to
discomfort, feeling unable to leave the home, I underwent 7 weeks of physiotherapy
resulting in isolation, developing low mood treatment. The first weeks were hard—
leading to postnatal depression. 200–202
holding and breastfeeding my newborn baby
were especially painful, and I felt extremely
The lived experience for women who suffer concerned about my future health. I was finding
perineal trauma, particularly those who experience it difficult to look after my newborn and the
a wound breakdown, may involve a long recovery worries about my future physical activity levels
with long-lasting impact on their family life. meant I felt quite low and found it difficult to
bond with my baby.

Patient portraits My baby is now 8 weeks old and I feel a huge

Patient narratives are an important and powerful amount better. I can now hold and feed my baby
way to communicate the impact of a medical without pain and have started to introduce a
treatment or intervention on an individual. The small amount of activity into my day. I am still
following patient narratives reveal the significant suffering from stress incontinence, but I hope that
health and wellbeing concerns of women who continuing with pelvic floor exercises will result
experienced birth-related wound problems.203 in a full recovery.

I am thankful for the vigilance and

Ellen's story conscientiousness of my community midwife and
What women say about perineal wounds to the physiotherapy team’s treatment and care. I
This narrative recounts the problems encountered, am now starting to enjoy my time with my baby
and the personal and family impact of a perineal and feel far more positive about my future health.
wound infection.

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Loretta's story and I couldn’t stand or walk or sit, all I could do was
Physical and psychological impact of to lie on my side. One midwife told me later when
episiotomy and lacerations I was leaving hospital that they were so concerned
In August 2016, at 41 years of age, I went into because they could smell the stench of the infection
labour with my first child. It had been a normal when they entered my room. A doctor finally came
pregnancy and I was feeling really positive about down to see me at 5am on the Monday morning.
the whole process. I’d educated myself at any When he did see the wound, it was clear that it was
available opportunity; went on an National in a very bad way. They drew around the edge of the
Childbirth Trust antenatal course and to all the red swollen area with a marker, and the line was out
NHS information days on offer. Nothing I had around my buttocks. I started oral antibiotics and a
seen (One Born every Minute) or read about births blood transfusion was also ordered. They took new
made me feel comfortable—but even so, none swabs, which took a day or so to produce results that
of the courses I took, or books that I read, even showed the bacteria were resistant to the antibiotics
mentioned the perineal trauma that was possible they were using. I was switched to IV antibiotics of a
after birth. much stronger kind. I had laser treatment from the
women’s health physio team every day, and again
My labour didn’t progress quickly, so I had their faces were a sign of how bad the wound was.
membranes ruptured and was given drugs to They told me that the wound had totally broken
speed things up. I also had an epidural at that down, so now it had to heal by secondary intent.
point. Once fully dilated, I pushed and pushed. I was also told I would probably need cosmetic/
I was keen to push the baby out as I knew the functional surgery to the perineum once the wound
alternative was going to be forceps. I asked during healed, no-one could or would estimate a time-
second stage, when the baby was stuck, if a scale for the healing. I was never given a date for
caesarean section was an option. I was told it was discharge, because it was a case of seeing how the
too late for that. After the birth, I was stitched up wound was responding to the antibiotics, but finally,
and sent to the ward with my baby. At this stage, I after 12 nights, it was deemed to be under control.
felt we were both OK and, so while it wasn’t what My husband had slept next to my bed in a chair for
I’d hoped for, it was definitely a good outcome. all the 12 nights, getting up when the baby woke to
bring her to me to feed because, if I stood for more
The first night was OK, and the next day, but the than a minute, I would start to bleed on the floor and
second night I felt feverish and swollen in the the pain would be excruciating. I was quite terrified
episiotomy and then there was a lot of pain in that of leaving the hospital because I didn’t know how I
area. The round doctor saw me and decided not to would cope at home: there was only myself and my
discharge me but to observe. She said there was an husband, we have no family who could help out. I
infection in the wound (acknowledged in my notes), was also really scared the infection would get worse
but antibiotics were not prescribed. It was now a again and no-one would know.
weekend and the women’s health physio team that
would normally have started treating the wound and After discharge, I was on oral antibiotics for another
haematoma were not back in until Monday. So, I was 2 weeks, and taking tramadol for the pain. I had
left with no treatment at all for an infection, which to go to the outpatients physio every other day for
then went rampant. I became more and more ill and laser treatment to the wound. I saw the physios for
was in severe pain. I couldn’t feed the baby easily something like 2 months, several times a week for

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the first weeks and then once per week after that. painful, looked like they were starting to open
At home I could only feed my daughter lying on and the area around them was starting to get
my side because of the pain when trying to sit. I quite red around. The next day (Saturday) I
was really confined to my bed, I couldn’t comfort checked again and the larger of the two areas
her by walking or rocking (even her tiny weight had some discharge, so I phoned the community
was too much to hold), I couldn’t hold her to wind midwife. She told me to go to Jessops (Jessop
her easily. I didn’t feel like I was being her mother. Wing, Hospital for Women, Sheffield Teaching
I desperately hoped she would feed quickly and Hospital NHS Trust, South Yorkshire, UK) to have
then go back to sleep because I was so tired myself. I it checked. I was seen first by a midwife who
never spent any time in those first weeks or months thought it looked fine and was healing nicely
actually enjoying her or bonding with her; I was just but would get one of the doctors to check. When
terrified of the demands she made on me when I the doctor came they weren’t too sure either
was so physically drained and in pain. I plummeted because the rest of the wound looked so healthy.
into postnatal depression and commenced They thought the small amount of discharge
antidepressants to aid my mood. was serous fluid. However, she decided to ‘play
it safe’ and take a swab. On the Thursday I got
In the months and years following I have had a a phone call from one of the doctors at Jessops
posterior vaginal wall repair and two episodes of as the results of the swabs were back and were
Botox for an anal fistula. I remain concerned for positive for two types of bacteria, and I needed
the future: I can’t jump on the trampoline with two types of antibiotics. Luckily, I think I spotted
my daughter, or pick her up and carry her when the signs of infection early enough that it
she’s tired or hurt. She sees me as boring and not didn’t cause me too many problems in terms of
adventurous, when I used to be anything but. healing although those two sections took longer
to heal and I probably took painkillers longer
So even though my wound did heal eventually because of the pain and discomfort from the
(after 4.5 months), the aftermath will seemingly be delayed healing.
with me for life.
I was lucky that I had extra help to look after my
older child (3 years old) and so someone else did
Victoria's story the nursery run for me so that I didn’t have to
What women say about caesarean worry about getting out. The main impact I feel
section wounds that it had on me was in relation to breastfeeding
This narrative demonstrates the need for (baby was combined fed due to other issues but
improvements in early assessment and prognosis always breastfed first). After taking a couple
of surgical wound infection. The narrative reveals of antibiotic doses, I felt my daughter was
the adverse impact of antibiotics on infant not feeding as well as she usually did. When
feeding as well as on the pain and sadness of not expressing, there was definitely a reduction in the
being able to continue with breast feeding. amount of milk. After a day or two, my daughter
would not latch and would not feed expressed
I first noticed there was a problem 10 days after milk either. The health visitor said that this
surgery. My wound had still been a bit painful could be due to the antibiotics affecting the taste.
to touch but I noticed that two areas were more Once I’d finished the antibiotics, I worked with

J O U R N A L O F WO U N D C A R E V O L 2 9 N O 1 1 E W M A D O C U M E N T 2 0 2 0  S33
the infant feeding workers and health visitor to 7. The Centers for Disease Control (CDC)
improve milk supply (I had continued to express continues to be regarded as a ‘gold standard’ as
during the course of antibiotics but it hadn’t been the global reporting definition for surgical site
used) and this helped me feed a little longer, but infection. A number of wound assessment tools
ultimately, it led to me moving to just formula (e.g. REEDA, TIMERS, DOMINATE) are available,
feeds much earlier than I wanted, which I am but have not been validated for all types of birth-
disappointed with and it did make me feel quite related wound infections. Other grading systems,
bad about myself at the time. for example by the World Union of Wound
Healing Societies (WUWHS) Sandy SWD grading
system204 for surgical wound dehiscence is the first
Key points to provide a clinical grading system.205
1. There are two categories of birth-related wounds.
Childbirth-related perineal trauma (CRPT) occurs as 8. Visual inspection of perineal wounds and
a result of perineal tears/lacerations and episiotomy. incisional wounds, with assessment by healthcare
Incisional wounds, typically Pfannenstiel incisions, workers, and any signs or symptoms to suggest
occur after caesarean section. Both forms of tissue infection, slowed healing or wound dehiscence
trauma can result in significant morbidity in should be reported promptly.
women after childbirth.
9. Controversies in care and clinical management
2. Infection at the surgical incision site, called a after both vaginal and caesarean section birth
surgical site infection (SSI), is most commonly exist, notably in the use of antimicrobial
of the superficial layers. Rare, but catastrophic, prophylaxis. Current WHO recommendations
infective complications occur as a result of are to use antibiotic prophylaxis for elective
necrotising fasciitis. and emergency caesarean section and third-
and fourth-degree perineal tears, but not
3. Risk for infection after caesarean section includes episiotomy.
patient and procedural factors linked to the
physiology and health status of the woman, as 10. Multiple courses of antibiotics after caesarean
well as to factors linked to the surgical procedure section increase the risk of antimicrobial
(including surgeon rank/expertise). resistance, especially in light of evidence of
antibiotic resistant bacteria recovered from
4. Understanding the elements contributing to risk infected caesarean section wounds
helps to avoid, as well as mitigate, damage to tissue.
11. Antibiotic stewardship now must play a key
5. Birth-related wounds acquire infectious agents role in CRPT and caesarean section care pathways.
from exogenous and endogenous sources. Maternal
reservoirs of infection are skin, genital tract and 12. There is currently limited high-quality
gastrointestinal tract. evidence to support the use of negative pressure
wound therapy (NPWT) for the prevention of SSI
6. Microbial communities within the female genital following caesarean section.
tract are polymicrobial. Distinct flora are located
not only within the vagina, but in the cervix, 13. Results of several systematic reviews comparing
perineum, uterus, fallopian tubes and placenta. the effectiveness of wound dressings in the

S34 J O U R N A L O F WO U N D C A R E V O L 2 9 N O 1 1 E W M A D O C U M E N T 2 0 2 0
prevention of surgical site infection suggest no clear wound or an infected caesarean section wound
benefit of one type of dressing over another. infection is distressing, painful and disruptive
to normal life. It is a shocking and unexpected
14. Significant physical and emotional problems reality and impacts on the wellbeing and mental
occur for many women after vaginal and caesarean health of the mother. This document attempts
section birth. There is clear need for CRPT to to provide the latest evidence for healthcare
be placed at the forefront of care and improved professionals for guiding care of the postpartum
education of midwives and, consequently, women. woman for optimum healing outcomes.

15. Complications during pregnancy increase for Wound complications for the postpartum mother
women with obesity. They are at a higher risk may be due to a number of factors, including
for a caesarean section, and caesarean section is infection, and are a result of a breakdown in the
an independent risk factor for wound infection. skin and muscle integrity. They incur significant
Overall 62% of women in England are overweight additional healthcare-related costs and an
or obese.206 additional burdern for the workforce.

16. Globally, there is an increasing trend for Childbirth-related wound complications

people to be overweight (pre-obese; BMI 25.0– affect the family and the mother and may be
29.9) and obese (BMI ≥30),207 including women devastating if ill health, pain and immobility
of childbearing age. Improvement in pre- and prevent the mother’s ability to nurture and bond
postnatal education on avoidance of risk requires with the newborn infant.
greater emphasis on assessment, screening and
rational interventions. Investment in maternity services research is
essential for our understanding of the extent of
wound-related complications for the postpartum
Summary and future mother and improved clinical pathways for
perspectives wound management. A shared model of care
This document has been produced, with the with the mother at the centre of the model
support of EWMA, to bring together two spheres is required to ensure optimal wound healing
of maternal healthcare that have traditionally outcomes. Future therapies for prevention
been addressed separately. Assessment of the and management of birth-related wound
mother pre- and postnatally can improve complications require extensive research and
postnatal care and healing outcomes. For most rapid translation into healthcare settings for
women, the impact of having an open perineal maximum patient benefit.

J O U R N A L O F WO U N D C A R E V O L 2 9 N O 1 1 E W M A D O C U M E N T 2 0 2 0  S35
Appendix 1. Patient guide: What can I do to help to prevent SSI?
FAQs about SSI Here are some things that you can do to help
reduce the risk that you will develop a SSI:
This patient guide is reprinted with kind
permission from Stryja et al.59 Before surgery:
• Tell your physician about other medical
What is a surgical site infection? problems you may have. Give up smoking as
A surgical site infection (SSI) is an infection that patients who smoke get more infections.
occurs after surgery in the part of body where the • Clean your skin thoroughly by having a shower
surgery took place. Surgical site infections can be before you have your operation.
msot commonly superficial, involving only the • Do not remove hair from the area where the
skin. Other SSI can be more serious; involving incision will be made. If necessary, this will
deeper tissues under the skin; organs of the body be done by the operating team using electric
affected by the procedure, or implanted material. clippers rather than razors as close to the time
that the incision is made as possible.
When should I be concerned?
SSI generally appears within a month after After surgery:
surgery. However, if an implant, e.g. a prosthetic • Make sure you understand how to care for your
joint or graft is left in the body during surgery, wound before you leave the hospital.
an SSI may develop very slowly and not become • Be sure to ask your healthcare worker how
apparent for several months. to clean the area of the wound 48 hours
after surgery.
What are the symptoms of SSI? • Always clean your hands with soap and water
They include redness and increased pain around before and after caring for your wound.
the area where you had a surgery, drainage of • If the wound starts to look red, leak green/yellow
green/yellow, cloudy fluid from the wound fluid, become more painful or the edges of the
and fever. skin split apart, then contact your doctor who
can assess whether there might be an infection.
Can SSIs be treated?
Yes, most SSIs can be treated with antibiotics.
Sometimes patients with SSIs also need another
operation to treat the infection. Your healthcare
professional will provide guidance on how to
manage your wound.

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