What is the treatment for Caesarean (C-section) delivery stitches in a postpartum woman?

Treatment of Caesarean Delivery Stitches

Subcuticular sutures should be used for skin closure in most cases, as this technique reduces wound separation compared to staples, and when a dressing is applied, it should remain in place for 48 hours postoperatively. 1, 2

Optimal Surgical Closure Technique

Skin Closure Method

• Use subcuticular sutures rather than staples for skin closure, as this approach demonstrates reduced wound separation rates and improved healing outcomes 1
• The peritoneum does not need to be closed, as closure is not associated with improved outcomes and only increases operative time 1
• In women with ≥2 cm of subcutaneous tissue, reapproximation of that tissue layer should be performed to reduce wound complications 1

Wound Dressing Management

• When a dressing is applied over the cesarean skin incision, leave it in place for 48 hours postoperatively 2
• This approach is supported by limited but consistent evidence for optimal wound healing 2

Postoperative Wound Care and Pain Management

Multimodal Analgesia Protocol

• Administer scheduled acetaminophen 650-1000 mg every 6 hours and NSAIDs (ibuprofen 600 mg every 6-8 hours or ketorolac 30 mg IV every 6 hours for 4 doses) as the foundation of pain control 1, 2
• Reserve short-acting opioids only for breakthrough pain despite scheduled non-opioids 1, 2
• If intrathecal morphine 50-100 μg was administered during spinal anesthesia, this provides 12-24 hours of excellent baseline analgesia and significantly reduces systemic opioid requirements 1, 3, 4

Infection Prevention

• Prophylactic antibiotics (first-generation cephalosporin within 60 minutes before incision) should have been administered preoperatively 1
• Additional antibiotic doses postoperatively are indicated only for: patients with obesity who did not receive preoperative azithromycin, cesarean lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or intra-amniotic infection 2
• Routine multi-dose prophylactic antibiotics are not recommended for all patients postoperatively 2

Enhanced Recovery Measures

Early Mobilization and Activity

• Begin ambulation starting 4 hours postoperatively to promote recovery and reduce thromboembolism risk 1, 2
• Use pedometers to incentivize early mobilization 2
• Remove urinary catheter immediately after cesarean delivery if placed during surgery 1

Nutritional Support

• Resume a regular diet within 2 hours after cesarean delivery to accelerate recovery 1
• Chewing gum may aid in return of bowel function, though it may be redundant if early oral intake is implemented 1

Thromboprophylaxis

• Use pneumatic compression stockings for mechanical thromboprophylaxis until ambulation in low-risk patients 1
• Reserve chemoprophylaxis with heparin for patients with additional risk factors; routine heparin is not recommended for all patients 1

Adjunctive Non-Pharmacological Interventions

Evidence-Based Adjuncts

• Apply abdominal binders postoperatively to potentially enhance comfort and wound support 1, 4
• Transcutaneous electrical nerve stimulation (TENS) can be used as an analgesic adjunct 1, 4
• Other complementary approaches with emerging evidence include acupressure, acupuncture, aromatherapy, massage, and reiki, though these should supplement rather than replace standard care 2, 5

Discharge Planning and Follow-Up

Timing of Discharge

• Hospital discharge may occur as early as 24-28 hours if close (1-2 days) outpatient neonatal follow-up is available due to potential for neonatal jaundice 2
• Otherwise, discharge at 48-72 hours postoperatively is appropriate 2

Discharge Medications

• Continue multimodal pain control with scheduled acetaminophen and ibuprofen at home 2
• If short-acting opioids are necessary, prescribe only 5-10 tablets rather than standard 30-tablet prescriptions, individualized based on inpatient opioid requirements 4, 2

Postpartum Counseling

• Counsel on optimal interpregnancy interval of 18-23 months 2
• Encourage exclusive breastfeeding for at least 6 months 2
• Advise quick resumption of physical activity and vaginal intercourse as tolerated 2
• Discuss contraception options including immediate postpartum IUD insertion or long-acting reversible contraception 2

Common Pitfalls to Avoid

• Do not routinely use staples for skin closure, as they increase wound separation rates compared to subcuticular sutures 1
• Do not prescribe excessive opioids at discharge; the standard 30-tablet prescription is unnecessary for most patients and contributes to opioid misuse 4, 2
• Do not delay oral intake or mobilization based on outdated practices; early feeding and ambulation improve outcomes 1, 2
• Do not close the peritoneum, as this adds operative time without benefit 1