What is the treatment for episiotomy wound dehiscence?

Treatment of Episiotomy Wound Dehiscence

Early surgical repair with adequate preoperative wound cleansing and intravenous antibiotics is the recommended treatment for episiotomy wound dehiscence, as it is safe and effective with a high success rate of approximately 94%. 1

Assessment and Diagnosis

• Episiotomy dehiscence (breakdown of the repair) is a common complication with reported rates of 0.21% to 24.6%, with higher rates following obstetrical anal sphincter injuries (OASIS) 2
• Infection is the most common cause of episiotomy dehiscence, identified in approximately 79% of cases 1
• A thorough examination should be performed to assess:
  • Extent of wound breakdown (superficial vs. complete)
  • Presence of infection (purulent discharge, erythema, edema)
  • Involvement of deeper structures (anal sphincter complex) 2

Treatment Algorithm

1. Initial Management

• Administer broad-spectrum antibiotics:
  • Second or third-generation cephalosporin (e.g., cefoxitin 2g IV)
  • For penicillin allergy: gentamicin 5 mg/kg plus clindamycin 900 mg or metronidazole 500 mg 2
• Perform thorough wound cleansing to remove debris and necrotic tissue 3
• Place Foley catheter before initiating repair to prevent urinary retention 2

2. Surgical Repair

• Early repair (within 6-7 days of dehiscence) is recommended over allowing healing by secondary intention 3, 1
• Ensure adequate anesthesia (regional or general) 2
• Ensure proper visualization with adequate lighting 2
• Perform surgical site preparation with povidone-iodine or chlorhexidine gluconate (if allergic to iodine) 2
• Use the following technique for repair:
  • Close each layer separately starting with vaginal epithelium and muscularis
  • Repair perineal body musculature
  • Close rectovaginal fascia and perineal skin 2
• Use continuous non-locking suturing techniques as they:
  • Distribute tension more evenly
  • Result in less pain for up to 10 days postpartum
  • Reduce need for analgesic use
  • Reduce need for suture removal 2
• Perform digital rectal examination after repair to ensure no sutures have penetrated the rectal mucosa 4

3. Special Considerations

• For complex or recurrent dehiscence with significant tissue loss:
  • Consider loco-regional flaps such as bilateral inferiorly based labia majora flaps 5
  • Vacuum-assisted closure (VAC) therapy may be appropriate for complex cases with large defects not amenable to primary closure 6
• For infected wounds:
  • Ensure adequate debridement before repair
  • Continue antibiotics postoperatively 1

4. Postoperative Care

• Administer pain control: acetaminophen, ibuprofen, ice packs (opiates only if needed) 2
• Recommend sitz baths twice daily until first wound check 2
• Prescribe stool softeners (polyethylene glycol 4450 or mineral oil twice daily) for six weeks postpartum to achieve soft stools and prevent strain on repair 2
• Arrange early follow-up within two weeks, ideally in a specialized postpartum perineal clinic 2
• Provide patient education on wound care and signs of complications 2

Outcomes and Prognosis

• Early repair has a success rate of approximately 94% 1
• Average time from repair to discharge is approximately 5-6 days 3
• Minor complications such as superficial separation of skin edges may occur in approximately 12% of cases but usually resolve with conservative management 3
• Patients with third-degree episiotomies have a higher risk of repair breakdown (approximately 6%) and may require healing by secondary intention 1

Prevention of Wound Complications

• Proper surgical technique during initial episiotomy repair using continuous non-locking sutures 2
• Preoperative antibiotics for high-risk repairs, particularly OASIS 2
• Proper postoperative care including sitz baths and stool softeners 2

By following this treatment algorithm, most episiotomy dehiscence cases can be successfully managed with early repair, resulting in faster healing and improved patient outcomes.