What are the signs of an infected episiotomy?

Signs of Infected Episiotomy

An infected episiotomy presents with purulent drainage, spreading erythema beyond the wound margins, warmth, tenderness, and swelling, typically developing 4-6 days postpartum, though early infections within 48 hours suggest virulent organisms like Group A Streptococcus or Clostridium species. 1

Local Signs of Infection

Classic Wound Infection Features

• Purulent drainage from the episiotomy site is diagnostic of surgical site infection and the most reliable indicator 1
• Spreading erythema extending beyond the wound margins, particularly >5 cm from the incision edge 1
• Warmth and tenderness at the wound site, beyond what is expected from normal healing 1
• Swelling and induration of the perineal tissues surrounding the episiotomy 1
• Wound dehiscence or breakdown of the suture line 1, 2

Distinguishing Normal vs. Infected Drainage

• Sanguinous (bloody) drainage alone without purulence does NOT meet criteria for infection 3
• Only purulent drainage (thick, opaque, often malodorous) indicates infection requiring intervention 1

Timing Considerations

Early Infection (First 48 Hours)

• Infections developing within 48 hours postpartum are rare but highly concerning 1, 4
• Early infections suggest virulent organisms: Group A Streptococcus or Clostridium species 1
• Severe, rapidly worsening pain at the episiotomy site beginning within 24 hours is the first reliable symptom of clostridial myonecrosis 1, 5
• Wound drainage may show organisms on Gram stain but white blood cells may be absent in early streptococcal or clostridial infections 1

Late Infection (After 48 Hours)

• Most episiotomy infections appear between days 4-6 postpartum and are typically polymicrobial 1
• By postoperative day 4, fever is equally likely to be from surgical site infection or other causes 1, 4

Systemic Signs

Indicators of Serious Infection

• Fever >38.5°C (101.3°F) 1, 3
• Tachycardia with heart rate >100-110 beats/minute 1, 3
• Hypotension suggesting septic shock 1, 6
• Oliguria or decreased urine output 1
• Altered mental status or decreased alertness 1

Severe Septic Presentations

• Group A Streptococcal infection can cause severe septic shock syndrome within days of delivery 6
• Patients may develop respiratory, cardiovascular, and renal insufficiency requiring intensive support 6
• Skin desquamation may occur with staphylococcal toxic shock syndrome, though the wound often appears deceptively benign 1

Life-Threatening Necrotizing Infections

Clostridial Myonecrosis (Gas Gangrene)

• Increasingly severe pain beginning 24 hours after delivery is the first reliable symptom 1, 5
• Skin progresses from pale to bronze to purplish-red 1
• Crepitus (gas in tissues) detected on palpation or imaging 1
• Bullae filled with reddish-blue fluid 1
• Tense, tender infected region 1
• Clostridium sordellii is now the most common species in serious episiotomy infections 5

Necrotizing Fasciitis (Fournier Gangrene Variant)

• Can involve the perineum, vulva, and surrounding tissues 1
• May have insidious or explosive onset 1
• Discrete area of necrosis that progresses rapidly over 1-2 days 1
• Advancing skin necrosis with spreading gangrene 1

Critical Red Flags Requiring Immediate Intervention

• Any signs of necrotizing infection (rapidly spreading necrosis, gas in tissues, severe systemic toxicity) require prompt surgical consultation 1
• Early infection with severe pain and systemic signs within 48 hours suggests Group A Streptococcus or Clostridium—requires immediate surgical exploration 1
• Erythema extending >5 cm from wound edge combined with fever or tachycardia requires urgent reassessment 1, 3
• Development of hypotension, oliguria, or altered mental status indicates septic shock requiring immediate aggressive management 1, 6

Common Pitfalls to Avoid

• Do not dismiss early severe pain as normal postpartum discomfort—this may be the only early sign of clostridial infection 1, 5
• Do not assume all postpartum fever is benign—carefully inspect the episiotomy wound for subtle signs of infection 1, 4
• Do not confuse sanguinous drainage with infection—only purulent drainage indicates infection 3
• Do not delay surgical exploration when necrotizing infection is suspected—mortality increases dramatically with delayed intervention 1